Healthcare Provider Details

I. General information

NPI: 1427103886
Provider Name (Legal Business Name): JEROME S GORDON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 CHURCH ST NE
SALEM OR
97301-2402
US

IV. Provider business mailing address

635 CHURCH ST NE
SALEM OR
97301-2402
US

V. Phone/Fax

Practice location:
  • Phone: 503-399-9691
  • Fax: 503-399-9401
Mailing address:
  • Phone: 503-399-9691
  • Fax: 503-399-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number682
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number682
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number682
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number682
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: