Provider Demographics
NPI:1922569409
Name:GORDON, IGNACIA ALEX
Entity Type:Individual
Prefix:MS
First Name:IGNACIA
Middle Name:ALEX
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 1:11801 NE 65TH ST # A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5527
Mailing Address - Country:US
Mailing Address - Phone:360-558-5790
Mailing Address - Fax:360-558-5791
Practice Address - Street 1:11801 NE 65TH ST # A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5527
Practice Address - Country:US
Practice Address - Phone:360-558-5790
Practice Address - Fax:360-558-5791
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60568892171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator