Provider Demographics
NPI:1497233969
Name:GORDON, JAYNE ELLEN X (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:ELLEN
Last Name:GORDON
Suffix:X
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OLD RUBBLY RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1509
Mailing Address - Country:US
Mailing Address - Phone:978-806-6360
Mailing Address - Fax:
Practice Address - Street 1:15 OLD RUBBLY RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1509
Practice Address - Country:US
Practice Address - Phone:978-806-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10153371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical