Provider Demographics
NPI:1780126789
Name:GORDON, JESSICA BUECHNER
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BUECHNER
Last Name: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 1:2310 MAIN ST
Mailing Address - Street 2:APT. #435
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-9146
Mailing Address - Country:US
Mailing Address - Phone:678-538-8854
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2358
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX#908084163W00000X
TXAP132488367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse