Provider Demographics
NPI:1992519144
Name:GORDON, JONATHAN ADAM
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ADAM
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 N ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8100 E 22ND ST N BLDG 2300-3
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2306
Practice Address - Country:US
Practice Address - Phone:513-680-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04963101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health