Provider Demographics
NPI:1023484292
Name:GORDILLO, JENNIFER ANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:GORDILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W HOSPITALITY LN STE 312
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3212
Mailing Address - Country:US
Mailing Address - Phone:866-205-3595
Mailing Address - Fax:
Practice Address - Street 1:325 W HOSPITALITY LN STE 312
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3212
Practice Address - Country:US
Practice Address - Phone:866-205-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF75155106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist