Provider Demographics
NPI:1457859787
Name:GASTON, JOHNENE ANN (BC-HIS)
Entity Type:Individual
Prefix:
First Name:JOHNENE
Middle Name:ANN
Last Name:GASTON
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 SPRINGPORT RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1454
Mailing Address - Country:US
Mailing Address - Phone:517-788-8000
Mailing Address - Fax:517-788-3898
Practice Address - Street 1:2266 SPRINGPORT RD UNIT D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1454
Practice Address - Country:US
Practice Address - Phone:517-788-8000
Practice Address - Fax:517-788-3898
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3208237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty