Provider Demographics
NPI:1568902278
Name:GORDON, JASON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 TAPO ST
Mailing Address - Street 2:STE B117
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3022
Mailing Address - Country:US
Mailing Address - Phone:805-765-4773
Mailing Address - Fax:805-392-9975
Practice Address - Street 1:321 N LARCHMONT BLVD STE 825
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6400
Practice Address - Country:US
Practice Address - Phone:323-464-4458
Practice Address - Fax:323-464-5329
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist