Provider Demographics
NPI:1376297630
Name:GORDON, JENNA T (FNP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:T
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14866 OCEAN HWY
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-4801
Mailing Address - Country:US
Mailing Address - Phone:843-900-0777
Mailing Address - Fax:843-900-0780
Practice Address - Street 1:14866 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-4801
Practice Address - Country:US
Practice Address - Phone:843-900-0777
Practice Address - Fax:843-900-0780
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily