Provider Demographics
NPI:1649415126
Name:GISHKIN, JEFFREY (MC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GISHKIN
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9445 S 50TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5629
Mailing Address - Country:US
Mailing Address - Phone:602-708-4719
Mailing Address - Fax:
Practice Address - Street 1:9445 S 50TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5629
Practice Address - Country:US
Practice Address - Phone:602-708-4719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC0181101YA0400X
AZLPC0079101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)