Provider Demographics
NPI:1669238069
Name:GORDON, JAMAL
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 SUNRISE VILLAGE LN APT B
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-5400
Mailing Address - Country:US
Mailing Address - Phone:407-427-4627
Mailing Address - Fax:
Practice Address - Street 1:3204 SUNRISE VILLAGE LN APT B
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5400
Practice Address - Country:US
Practice Address - Phone:407-427-4627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA268561171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach