Provider Demographics
NPI:1508330861
Name:GORDON, JAN MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10320 RIDGE LINE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-7738
Mailing Address - Country:US
Mailing Address - Phone:317-823-8984
Mailing Address - Fax:
Practice Address - Street 1:10320 RIDGE LINE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-7738
Practice Address - Country:US
Practice Address - Phone:317-823-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004719A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical