Healthcare Provider Details

I. General information

NPI: 1376094466
Provider Name (Legal Business Name): KIRSTYN JANE GORDON MSW, LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE STE 300
JACKSON MI
49202-2174
US

IV. Provider business mailing address

3768 MONROE RD
TIPTON MI
49287-9813
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: