Provider Demographics
NPI:1518359736
Name:GORDON, JESSICA M
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 HIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6067
Mailing Address - Country:US
Mailing Address - Phone:260-797-3604
Mailing Address - Fax:
Practice Address - Street 1:4703 HIGHWOOD DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6067
Practice Address - Country:US
Practice Address - Phone:260-797-3604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0501147343347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle