Provider Demographics
NPI:1770012700
Name:GUST, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GUST
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 1:8022 S RAINBOW BLVD STE 318
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6477
Mailing Address - Country:US
Mailing Address - Phone:702-328-1760
Mailing Address - Fax:
Practice Address - Street 1:2340 E CALVADA BLVD STE E
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-6099
Practice Address - Country:US
Practice Address - Phone:702-327-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-04
Last Update Date:2017-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner