Provider Demographics
NPI:1649383886
Name:GORDON, JAMIE LEE (LPC-S)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:SUMMERS STACKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-S
Mailing Address - Street 1:110 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3362
Mailing Address - Country:US
Mailing Address - Phone:479-967-5570
Mailing Address - Fax:479-890-5364
Practice Address - Street 1:920 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-5148
Practice Address - Country:US
Practice Address - Phone:501-620-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0509059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional