Provider Demographics
NPI:1801037601
Name:GUSTAFSON, JENNIFER LYND MOSEY (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYND MOSEY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12758 DIAMOND PATH
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8375
Mailing Address - Country:US
Mailing Address - Phone:612-619-6887
Mailing Address - Fax:
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-798-8167
Practice Address - Fax:612-861-3446
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1710106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist