Provider Demographics
NPI:1629798814
Name:GORDON, JESSICA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 TIMBER OAKS LN APT G
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6516
Mailing Address - Country:US
Mailing Address - Phone:845-772-1016
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6000
Practice Address - Country:US
Practice Address - Phone:980-993-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist