Provider Demographics
NPI:1114029550
Name:GORDON, JACOB L (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:L
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVENUE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-6478
Mailing Address - Fax:253-968-9054
Practice Address - Street 1:9040 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-6478
Practice Address - Fax:253-968-9054
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010772702084N0400X, 2084S0012X
PAMD4379802084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023686220002Medicaid
G13120Medicare UPIN