Provider Demographics
NPI:1619660438
Name:GORDON, JASMINE ROSE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ROSE
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 1:9340 E STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1558
Mailing Address - Country:US
Mailing Address - Phone:916-509-8199
Mailing Address - Fax:
Practice Address - Street 1:9340 E STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1558
Practice Address - Country:US
Practice Address - Phone:916-509-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator