Provider Demographics
NPI:1467227884
Name:GORDON, JASON ALEXANDER
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALEXANDER
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6982 COMISKEY PARK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-8042
Mailing Address - Country:US
Mailing Address - Phone:702-292-0887
Mailing Address - Fax:
Practice Address - Street 1:6982 COMISKEY PARK ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166-8042
Practice Address - Country:US
Practice Address - Phone:702-292-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCHW1-5486172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker