Provider Demographics
NPI:1659586220
Name:GORDON-NORBY, JENNIFER J (MS, PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:GORDON-NORBY
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-0193
Mailing Address - Country:US
Mailing Address - Phone:303-857-1111
Mailing Address - Fax:303-857-1198
Practice Address - Street 1:150 MAIN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1852
Practice Address - Country:US
Practice Address - Phone:303-857-1111
Practice Address - Fax:303-857-1198
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54858046Medicaid
CO492998Medicare ID - Type Unspecified
COC493008Medicare UPIN