Provider Demographics
NPI:1447444765
Name:GORDER, JENIFER LAYNE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:LAYNE
Last Name:GORDER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 WHISTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401
Mailing Address - Country:US
Mailing Address - Phone:801-548-2231
Mailing Address - Fax:
Practice Address - Street 1:2129 WHISTON ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401
Practice Address - Country:US
Practice Address - Phone:801-548-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE
UT000055266Medicare PIN