Provider Demographics
NPI:1710667993
Name:GORDON, JACQUELINE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
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 1:842 S GREEN RD APT 5
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3461
Mailing Address - Country:US
Mailing Address - Phone:434-386-7721
Mailing Address - Fax:
Practice Address - Street 1:100 RICHMOND RD APT 313
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44143-1252
Practice Address - Country:US
Practice Address - Phone:216-240-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant