Provider Demographics
NPI:1750920658
Name:TAYLOR GORDON, BE'IANKA JAZZ'E
Entity type:Individual
Prefix:
First Name:BE'IANKA
Middle Name:JAZZ'E
Last Name:TAYLOR 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 1:51 MIDDLE ROSE ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-3803
Mailing Address - Country:US
Mailing Address - Phone:609-917-4774
Mailing Address - Fax:
Practice Address - Street 1:819 ALEXANDER RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-6303
Practice Address - Country:US
Practice Address - Phone:609-759-7454
Practice Address - Fax:609-452-0627
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07101900164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ251S0000XMedicaid