Provider Demographics
NPI:1538213103
Name:WHITE, JEFFREY GORDON (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GORDON
Last Name:WHITE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 WILLOWBEND TRL
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9593
Mailing Address - Country:US
Mailing Address - Phone:917-355-5801
Mailing Address - Fax:
Practice Address - Street 1:8036 MOORSBRIDGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4419
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073031041C0700X
NY0765621041C0700X
MI68010933251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical