Provider Demographics
NPI:1285085118
Name:GATEWOOD, JENNAN M
Entity type:Individual
Prefix:
First Name:JENNAN
Middle Name:M
Last Name:GATEWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7034 CONNER POINTE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2093
Mailing Address - Country:US
Mailing Address - Phone:618-978-4427
Mailing Address - Fax:
Practice Address - Street 1:5831 GEIGER RD
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:IL
Practice Address - Zip Code:62001-2227
Practice Address - Country:US
Practice Address - Phone:618-978-4427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency