Provider Demographics
NPI:1730300575
Name:GASTINEAU, JENNIFER L (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:GASTINEAU
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GASTINEAU-BENJAMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:1970 RAWHIDE DR
Mailing Address - Street 2:SUITE #318
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-6957
Mailing Address - Country:US
Mailing Address - Phone:512-388-3638
Mailing Address - Fax:512-388-3634
Practice Address - Street 1:1970 RAWHIDE DR
Practice Address - Street 2:SUITE 318
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-6957
Practice Address - Country:US
Practice Address - Phone:512-388-3638
Practice Address - Fax:512-388-3634
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19994101YP2500X, 101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1788267Medicaid