Basic Information
| Provider Information | |||||||||
| NPI: | 1104201516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUTNEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177517802 | ||||||||
| FaxNumber: | 8479595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 6100 WESTERN PL | ||||||||
| Address2: | SUITE 908 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177517802 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMH 11823 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 76281 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 339765 | 01 | NCC | OTHER |