Provider Demographics
NPI:1659523413
Name:GASTON, JENNY (LPC)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:DELACRUZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:5523 DELANCEY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1309
Mailing Address - Country:US
Mailing Address - Phone:215-758-7889
Mailing Address - Fax:
Practice Address - Street 1:3905 FORD RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2824
Practice Address - Country:US
Practice Address - Phone:215-878-3400
Practice Address - Fax:215-878-2082
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005719101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-1728027Medicaid