Provider Demographics
NPI:1437112034
Name:GORDON, JENNIFER (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 DERBY DR
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-1208
Mailing Address - Country:US
Mailing Address - Phone:410-456-7115
Mailing Address - Fax:
Practice Address - Street 1:2502 DERBY DR
Practice Address - Street 2:
Practice Address - City:FALLSTON
Practice Address - State:MD
Practice Address - Zip Code:21047-1208
Practice Address - Country:US
Practice Address - Phone:410-456-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00001982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer