Provider Demographics
NPI:1669843124
Name:GORDON, JENNIFER A (CADC-II)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:GORDON
Suffix:
Gender:F
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 ARLINGTON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504
Mailing Address - Country:US
Mailing Address - Phone:951-351-1409
Mailing Address - Fax:
Practice Address - Street 1:4295 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-341-3786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)