Provider Demographics
NPI:1336633866
Name:GORDON-JACKSON, SHEREE N (BSW)
Entity Type:Individual
Prefix:
First Name:SHEREE
Middle Name:N
Last Name:GORDON-JACKSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:SHEREE
Other - Middle Name:N
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20600 CHAGRIN BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5334
Practice Address - Country:US
Practice Address - Phone:216-295-7239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2001613-TRNE104100000X
172V00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker