Provider Demographics
NPI:1295954972
Name:GORDON, JACQUELINE CAROL (MFT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:CAROL
Last Name:GORDON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22637 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7943
Mailing Address - Country:US
Mailing Address - Phone:951-609-4123
Mailing Address - Fax:951-244-4269
Practice Address - Street 1:43537 RIDGE PARK DR
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3615
Practice Address - Country:US
Practice Address - Phone:951-609-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42439106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC42439OtherLICENSE NO.