Provider Demographics
NPI:1629547062
Name:GORDON, JACQUALYNN SCOT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACQUALYNN
Middle Name:SCOT
Last Name:GORDON
Suffix:
Gender:F
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 1:380 STEVENS AVE STE 314
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2069
Mailing Address - Country:US
Mailing Address - Phone:858-755-5200
Mailing Address - Fax:858-755-5201
Practice Address - Street 1:380 STEVENS AVE STE 314
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2069
Practice Address - Country:US
Practice Address - Phone:858-755-5200
Practice Address - Fax:858-755-5201
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist