Provider Demographics
NPI:1295905867
Name:GORDON, JESSICA SUSAN (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1799 VALENZANO WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-7207
Mailing Address - Country:US
Mailing Address - Phone:702-496-2200
Mailing Address - Fax:702-837-0627
Practice Address - Street 1:6900 PECOS RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1295905867Medicaid