Provider Demographics
NPI:1477806073
Name:GORHAM, JENNIFER (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GORHAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2429
Mailing Address - Country:US
Mailing Address - Phone:774-312-6667
Mailing Address - Fax:
Practice Address - Street 1:121 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2429
Practice Address - Country:US
Practice Address - Phone:774-312-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical