Provider Demographics
NPI:1215008495
Name:GORDON, JEFFREY STEPHEN (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:STEPHEN
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:PO BOX 81062
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-1062
Mailing Address - Country:US
Mailing Address - Phone:907-479-0623
Mailing Address - Fax:888-761-9303
Practice Address - Street 1:1755 WESTWOOD WAY # 7
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4064
Practice Address - Country:US
Practice Address - Phone:907-479-0623
Practice Address - Fax:888-761-9303
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5926225100000X
AK1784225100000X
NC12294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT5613Medicaid
AKPT5613Medicaid