Provider Demographics
NPI:1982808176
Name:GUNN, GORDON JACK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:JACK
Last Name:GUNN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 S CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-8292
Mailing Address - Country:US
Mailing Address - Phone:435-773-1117
Mailing Address - Fax:
Practice Address - Street 1:2458 S CAMINO REAL
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-8292
Practice Address - Country:US
Practice Address - Phone:435-773-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121756-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health