Provider Demographics
NPI:1295171775
Name:GORDON, JAMES WILLIAM JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
Last Name:GORDON
Suffix:JR
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 1:22 W SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 WALNUT AVE STE 207
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ37PC00710200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health