Provider Demographics
NPI:1376094466
Name:GORDON, KIRSTYN JANE (MSW, LLMSW)
Entity Type:Individual
Prefix:
First Name:KIRSTYN
Middle Name:JANE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSW, LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3768 MONROE RD
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:MI
Mailing Address - Zip Code:49287-9813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2174
Practice Address - Country:US
Practice Address - Phone:517-789-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker