Basic Information
| Provider Information | |||||||||
| NPI: | 1760709950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA, PSRS, CM II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | GRANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803723645 | ||||||||
| FaxNumber: | 5802986699 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | ANTLERS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745232238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803723645 | ||||||||
| FaxNumber: | 5802986699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2010 | ||||||||
| LastUpdateDate: | 04/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.