Provider Demographics
NPI:1194913665
Name:GORDON, JACQUELYNE (LCPC)
Entity type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630973
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-0973
Mailing Address - Country:US
Mailing Address - Phone:410-286-2833
Mailing Address - Fax:410-286-2834
Practice Address - Street 1:2021 CHANEYVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:OWINGS
Practice Address - State:MD
Practice Address - Zip Code:20736-4348
Practice Address - Country:US
Practice Address - Phone:410-286-2833
Practice Address - Fax:410-286-2834
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional