Provider Demographics
NPI:1386655900
Name:GORDON, JAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 DEVON WOOD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1212
Mailing Address - Country:US
Mailing Address - Phone:210-698-5561
Mailing Address - Fax:210-698-2668
Practice Address - Street 1:1602 N LOOP 1604 W
Practice Address - Street 2:SUITE LL-102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-4513
Practice Address - Country:US
Practice Address - Phone:210-479-3231
Practice Address - Fax:210-493-7273
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044047OtherVALUE OPTIONS
TXG35YOtherBLUE CROSS BLUE SHIELD OF