Provider Demographics
NPI:1063786564
Name:GORDON, JENNIFER E
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:GORDON
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 1:13726 S OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:DE
Mailing Address - Zip Code:19941-3330
Mailing Address - Country:US
Mailing Address - Phone:302-424-2080
Mailing Address - Fax:
Practice Address - Street 1:13726 S OLD STATE RD
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:DE
Practice Address - Zip Code:19941-3330
Practice Address - Country:US
Practice Address - Phone:302-424-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)