Provider Demographics
NPI:1225187065
Name:GORDON, JAMIE S (MSP, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:S
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 OSPREY NEST CT
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8024
Mailing Address - Country:US
Mailing Address - Phone:803-786-5981
Mailing Address - Fax:
Practice Address - Street 1:116 OSPREY NEST CT
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-8024
Practice Address - Country:US
Practice Address - Phone:803-786-5981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0583Medicaid