Provider Demographics
NPI:1417490343
Name:GORDON, JEREMY ELIJAH
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ELIJAH
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEREMY
Other - Middle Name:ELIJAH
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-3505
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:918-786-4435
Practice Address - Street 1:1115 HARBOR RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-3505
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:918-786-4435
Is Sole Proprietor?:No
Enumeration Date:2016-11-25
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator