Provider Demographics
NPI:1235396441
Name:GORDON, JERRY (LPC, MED)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LPC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 N STEMMONS FWY
Mailing Address - Street 2:SUITE#4015-H
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-3832
Mailing Address - Country:US
Mailing Address - Phone:214-882-2269
Mailing Address - Fax:
Practice Address - Street 1:8500 N STEMMONS FWY
Practice Address - Street 2:SUITE#4015-H
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-3832
Practice Address - Country:US
Practice Address - Phone:214-882-2269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX770101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095286302Medicaid