Basic Information
| Provider Information | |||||||||
| NPI: | 1770949307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2370 W. CLEVELAND AVE. | ||||||||
| Address2: | SUITE 108 #320 | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2445 W WHITES BRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937061225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592645096 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPCC5007 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.