Provider Demographics
NPI:1164590253
Name:GORDON, JERLENA T (APRN-BC)
Entity Type:Individual
Prefix:
First Name:JERLENA
Middle Name:T
Last Name:GORDON
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6045
Mailing Address - Country:US
Mailing Address - Phone:901-369-1420
Mailing Address - Fax:901-369-1433
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1420
Practice Address - Fax:901-369-1433
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26679363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3345918Medicare ID - Type Unspecified