Provider Demographics
NPI:1700059094
Name:GORDON, JENNIFER ERIN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ERIN
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E BROAD ST
Mailing Address - Street 2:11 TH FL.
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-9930
Mailing Address - Fax:614-644-9116
Practice Address - Street 1:30 E BROAD ST
Practice Address - Street 2:11TH FL. ATTN: MARY KYLE
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3414
Practice Address - Country:US
Practice Address - Phone:614-466-9930
Practice Address - Fax:614-644-9116
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6361103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist