Provider Demographics
NPI:1972035335
Name:GARDNER, RJAI DE RICO (BA CSS)
Entity Type:Individual
Prefix:MR
First Name:RJAI
Middle Name:DE RICO
Last Name:GARDNER
Suffix:
Gender:M
Credentials:BA CSS
Other - Prefix:MR
Other - First Name:RJAI
Other - Middle Name:DE RICO
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA CSS
Mailing Address - Street 1:428 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1945
Mailing Address - Country:US
Mailing Address - Phone:662-241-7097
Mailing Address - Fax:662-245-0511
Practice Address - Street 1:428 24TH AVE N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1945
Practice Address - Country:US
Practice Address - Phone:662-241-7097
Practice Address - Fax:662-245-0511
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor