Provider Demographics
NPI:1235106287
Name:GUDORF, JERRY E (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:E
Last Name:GUDORF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 S BRIDGETON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-6364
Mailing Address - Country:US
Mailing Address - Phone:574-291-9507
Mailing Address - Fax:574-283-1313
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-234-0061
Practice Address - Fax:574-283-1209
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340022401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S24677Medicare UPIN
IN237580LMedicare ID - Type Unspecified