Basic Information
| Provider Information | |||||||||
| NPI: | 1871949693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLIVER | ||||||||
| FirstName: | JANNA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSKIRK | ||||||||
| OtherFirstName: | JANNA | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 330 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177877920 | ||||||||
| FaxNumber: | 5177872440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 LAKE LANSING ROAD | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489122121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104947180 | ||||||||
| FaxNumber: | 8102151334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6801099629 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.