Provider Demographics
NPI:1336788363
Name:JEAN GAUTREAUX LLC
Entity type:Organization
Organization Name:JEAN GAUTREAUX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-405-2583
Mailing Address - Street 1:2257 WHITESIDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6044
Mailing Address - Country:US
Mailing Address - Phone:321-405-2583
Mailing Address - Fax:
Practice Address - Street 1:4630 LIPSCOMB ST NE STE 1A
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2940
Practice Address - Country:US
Practice Address - Phone:321-405-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty