Provider Demographics
NPI:1891295960
Name:GORDON, JASMINE TIERRA (LCSW)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:TIERRA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CIDER MILL WAY
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-3311
Mailing Address - Country:US
Mailing Address - Phone:984-289-8127
Mailing Address - Fax:
Practice Address - Street 1:709 CIDER MILL WAY
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-3311
Practice Address - Country:US
Practice Address - Phone:984-289-8127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0130481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty