Provider Demographics
NPI:1760709950
Name:GORDON, JENNIFER ANNE (BA, PSRS, CM II)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANNE
Last Name:GORDON
Suffix:
Gender:F
Credentials:BA, PSRS, CM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:OK
Mailing Address - Zip Code:74738
Mailing Address - Country:US
Mailing Address - Phone:580-372-3645
Mailing Address - Fax:580-298-6699
Practice Address - Street 1:301 N HIGH ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2238
Practice Address - Country:US
Practice Address - Phone:580-372-3645
Practice Address - Fax:580-298-6699
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor