Provider Demographics
NPI:1851050439
Name:GULLEY, JORDAN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:
Last Name:GULLEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 JOHN CARLYLE ST APT 313
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-6849
Mailing Address - Country:US
Mailing Address - Phone:804-366-6823
Mailing Address - Fax:
Practice Address - Street 1:800 JOHN CARLYLE ST APT 313
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-6849
Practice Address - Country:US
Practice Address - Phone:804-366-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500812321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0OtherVARIOUS