Provider Demographics
NPI:1164012993
Name:SIMON, JERRY GORDON
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:GORDON
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 HENDERSON BLVD STE 100E
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2999
Mailing Address - Country:US
Mailing Address - Phone:813-391-5909
Mailing Address - Fax:813-864-6741
Practice Address - Street 1:3314 HENDERSON BLVD STE 100E
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2999
Practice Address - Country:US
Practice Address - Phone:813-391-5909
Practice Address - Fax:813-864-6741
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104946200Medicaid