Basic Information
| Provider Information | |||||||||
| NPI: | 1730300575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GASTINEAU | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GASTINEAU-BENJAMIN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A., LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1970 RAWHIDE DR | ||||||||
| Address2: | SUITE #318 | ||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786816957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123883638 | ||||||||
| FaxNumber: | 5123883634 | ||||||||
| Practice Location | |||||||||
| Address1: | 1970 RAWHIDE DR | ||||||||
| Address2: | SUITE 318 | ||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786816957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123883638 | ||||||||
| FaxNumber: | 5123883634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 19994 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 19994 | TX | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 19994 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1788267 | 05 | TX | MEDICAID |