Basic Information
| Provider Information | |||||||||
| NPI: | 1013097161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | IVY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022234738 | ||||||||
| FaxNumber: | 8022236067 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTPELIER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056022702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022234738 | ||||||||
| FaxNumber: | 8022236067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 089-0000857 | VT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1008603 | 05 | VT | MEDICAID |