Provider Demographics
NPI:1013497593
Name:GORDON, JACQUELIN MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELIN
Other - Middle Name:MARIE
Other - Last Name:ASARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 NOYES ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3852
Mailing Address - Country:US
Mailing Address - Phone:315-738-3800
Mailing Address - Fax:
Practice Address - Street 1:1400 NOYES ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3852
Practice Address - Country:US
Practice Address - Phone:315-738-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252399-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0521Medicaid