Provider Demographics
NPI:1043951569
Name:GORDON-JONES, TEQUILA S
Entity Type:Individual
Prefix:
First Name:TEQUILA
Middle Name:S
Last Name:GORDON-JONES
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 1:3110 GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-7030
Mailing Address - Country:US
Mailing Address - Phone:843-309-4150
Mailing Address - Fax:
Practice Address - Street 1:408 GENEVA AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-5336
Practice Address - Country:US
Practice Address - Phone:843-423-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC123577C14376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator