Provider Demographics
NPI:1659850121
Name:GARDNER, JETAUN T (LSW)
Entity type:Individual
Prefix:
First Name:JETAUN
Middle Name:T
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9335 CALUMET AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4176
Mailing Address - Country:US
Mailing Address - Phone:219-836-9200
Mailing Address - Fax:219-836-4200
Practice Address - Street 1:9335 CALUMET AVE STE D
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4176
Practice Address - Country:US
Practice Address - Phone:219-836-9200
Practice Address - Fax:219-836-4200
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99087806A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical