Provider Demographics
NPI:1609387877
Name:GORDON, JARRETT (EDS)
Entity type:Individual
Prefix:
First Name:JARRETT
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-1628
Mailing Address - Country:US
Mailing Address - Phone:815-624-4006
Mailing Address - Fax:
Practice Address - Street 1:1050 E UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-1628
Practice Address - Country:US
Practice Address - Phone:815-624-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool