Provider Demographics
NPI:1023583721
Name:GORMAN, JERRY ANDREW (MSW)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ANDREW
Last Name:GORMAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BECK AVE # MS 5-250
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6804
Mailing Address - Country:US
Mailing Address - Phone:707-784-8355
Mailing Address - Fax:707-784-8355
Practice Address - Street 1:275 BECK AVE # MS 5-250
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6804
Practice Address - Country:US
Practice Address - Phone:707-784-8355
Practice Address - Fax:707-784-8355
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW933901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health