Provider Demographics
NPI:1073668596
Name:GORDON, JEROME JR (OTR-L)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:GORDON
Suffix:JR
Gender:M
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0587
Mailing Address - Country:US
Mailing Address - Phone:504-813-4968
Mailing Address - Fax:
Practice Address - Street 1:787 E NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4945
Practice Address - Country:US
Practice Address - Phone:504-813-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist