Provider Demographics
NPI:1609151158
Name:JENNIFER L. STREETS GLADWIN, LLC
Entity Type:Organization
Organization Name:JENNIFER L. STREETS GLADWIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:STREETS GLADWIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LMHC
Authorized Official - Phone:309-507-1791
Mailing Address - Street 1:3481 UTICA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1617
Mailing Address - Country:US
Mailing Address - Phone:309-507-1791
Mailing Address - Fax:
Practice Address - Street 1:3481 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1617
Practice Address - Country:US
Practice Address - Phone:309-507-1791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty