1134756737 NPI number — MRS. MORGAN JEAN PETERSON GARDNER BCA BA

Table of content: MRS. MORGAN JEAN PETERSON GARDNER BCA BA (NPI 1134756737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134756737 NPI number — MRS. MORGAN JEAN PETERSON GARDNER BCA BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
MORGAN
Provider Middle Name:
JEAN PETERSON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCA BA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
MORGAN
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134756737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2353 BADGER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-2302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-273-1121
Provider Business Mailing Address Fax Number:
906-225-6706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2353 BADGER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-273-1121
Provider Business Practice Location Address Fax Number:
906-225-6706
Provider Enumeration Date:
03/24/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106E00000X , with the licence number:  22159090657 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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