Provider Demographics
NPI:1750765673
Name:GORDON, JENNIFER D (FNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1101 BEAUMONT CENTRE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1758
Mailing Address - Country:US
Mailing Address - Phone:606-510-7778
Mailing Address - Fax:
Practice Address - Street 1:331 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-1215
Practice Address - Country:US
Practice Address - Phone:502-839-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015411363LF0000X
TXAP129820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA004470OtherABON
TXAP129820OtherLICENSE