Provider Demographics
NPI:1609590710
Name:GASTON, JACQUELYNN (MA, PLPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 SAPPHIRE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1889
Mailing Address - Country:US
Mailing Address - Phone:314-368-2409
Mailing Address - Fax:
Practice Address - Street 1:10830 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-1508
Practice Address - Country:US
Practice Address - Phone:314-368-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021028262101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021028262OtherINSURANCE