Basic Information
| Provider Information | |||||||||
| NPI: | 1669843124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CADC-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5870 ARLINGTON AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513511409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4295 BROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513413786 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.