Provider Demographics
NPI:1124591573
Name:GORDON, KENISHA WHEELER (LPC)
Entity Type:Individual
Prefix:DR
First Name:KENISHA
Middle Name:WHEELER
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC
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 587
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:787 E NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4945
Practice Address - Country:US
Practice Address - Phone:985-517-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1327101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional