Provider Demographics
NPI:1548669146
Name:GOLD, JENNIFER (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-8537
Mailing Address - Country:US
Mailing Address - Phone:785-825-6224
Mailing Address - Fax:785-825-7595
Practice Address - Street 1:617 E ELM ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401
Practice Address - Country:US
Practice Address - Phone:785-825-6224
Practice Address - Fax:785-825-7595
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00850061101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200363150AMedicaid