Provider Demographics
NPI:1720405962
Name:GORDON, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
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 1:16457 E BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-2721
Mailing Address - Country:US
Mailing Address - Phone:602-725-4854
Mailing Address - Fax:
Practice Address - Street 1:16807 E PALISADES BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-8438
Practice Address - Country:US
Practice Address - Phone:480-765-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4454374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician