Provider Demographics
NPI:1104004886
Name:GORDON, JONATHAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 CLAYTON RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1637
Mailing Address - Country:US
Mailing Address - Phone:314-644-1978
Mailing Address - Fax:314-647-1350
Practice Address - Street 1:6744 CLAYTON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1637
Practice Address - Country:US
Practice Address - Phone:314-644-1978
Practice Address - Fax:314-647-1350
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist