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General NPI Number Information
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NPI Number | 1124591573
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Entity Type | Individual
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Provider Name | KENISHA WHEELER GORDON LPC
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Gender | Female
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Dates
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Enumeration Date | 01/09/2019
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Last Update Date | 07/15/2019
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Provider Practice Location Address
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Address Line | 787 E NORTHSIDE DR
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City | JACKSON
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State | MS
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Zip | 39206-4945
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Country | US
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Telephone | 985-517-9300
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 587
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City | CLINTON
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State | MS
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Zip | 39060-0587
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1327
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License Number State | MS
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