Basic Information
| Provider Information | |||||||||
| NPI: | 1932745767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN MARIE | ||||||||
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| Credential: | MA, LMHC, MHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984053926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534414742 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1202 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984053926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534414742 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2019 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | MC61104696 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MG61104547 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | LH61330804 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.