Provider Demographics
NPI:1437215464
Name:JONES, GORDON WENDELL (CRT)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:WENDELL
Last Name:JONES
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492615
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2615
Mailing Address - Country:US
Mailing Address - Phone:530-221-8731
Mailing Address - Fax:530-221-8731
Practice Address - Street 1:2468 BIRCHWOOD CIR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-3748
Practice Address - Country:US
Practice Address - Phone:530-221-8731
Practice Address - Fax:530-221-8731
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF18701247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ59907ZMedicaid
CAZZZ59907ZMedicaid