Provider Demographics
NPI:1538609516
Name:GULICK, JENNIFER SOFIE (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SOFIE
Last Name:GULICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SOFIE
Other - Middle Name:
Other - Last Name:GULICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1868
Mailing Address - Country:US
Mailing Address - Phone:307-733-2046
Mailing Address - Fax:
Practice Address - Street 1:640 E BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1735101YP2500X
WYPPC-945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health