Provider Demographics
NPI:1366821357
Name:GIPSON, JORDAN HEATH (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:HEATH
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DRIVE
Mailing Address - Street 2:MCHE/ME
Mailing Address - City:JBSA FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-916-0808
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DRIVE
Practice Address - Street 2:MCHE/ME
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261725208D00000X
MO2019032244207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice