Provider Demographics
NPI:1588765002
Name:GORDON, SCOTT JASON (MED, LPC)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:JASON
Last Name:GORDON
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 BLUE GRASS CT
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-6861
Mailing Address - Country:US
Mailing Address - Phone:919-639-6603
Mailing Address - Fax:919-662-2372
Practice Address - Street 1:174 BLUE GRASS CT
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-6861
Practice Address - Country:US
Practice Address - Phone:919-639-6603
Practice Address - Fax:919-662-2372
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3370101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102316Medicaid