Provider Demographics
NPI:1356862155
Name:GABILONDO, JORDAN LITTLE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LITTLE
Last Name:GABILONDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E BURNSIDE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1300
Mailing Address - Country:US
Mailing Address - Phone:541-961-1317
Mailing Address - Fax:
Practice Address - Street 1:7632 SE FLAVEL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-7813
Practice Address - Country:US
Practice Address - Phone:503-467-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0177OtherJANUS YOUTH PROGRAM