Provider Demographics
NPI:1760965388
Name:GORDON, JOHNATHAN PAUL
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:PAUL
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4203
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-876-3436
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-876-3436
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6386104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker