Provider Demographics
NPI:1922054949
Name:GISH, JENNIFER MARY (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARY
Last Name:GISH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10560 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1524
Mailing Address - Country:US
Mailing Address - Phone:952-595-0562
Mailing Address - Fax:952-595-0564
Practice Address - Street 1:10560 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1524
Practice Address - Country:US
Practice Address - Phone:952-595-0562
Practice Address - Fax:952-595-0564
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN127674OtherBEHAVIORAL HEALTH CARE PR
MNHP30670OtherHEALTH PARTNERSW
MN167437OtherCOMPSYCH
MN6262800OtherUNITED BEHAVIORAL HEALTH
MN25G83GIOtherBLUE CROSS BLUE SHIELD