Provider Demographics
NPI:1093492217
Name:GORDON, MELINDA DAWN
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:DAWN
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-0125
Mailing Address - Country:US
Mailing Address - Phone:731-334-1666
Mailing Address - Fax:
Practice Address - Street 1:384 CARRIAGE HOUSE DR STE C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2268
Practice Address - Country:US
Practice Address - Phone:731-868-7297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6617101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional