Provider Demographics
NPI:1114029550
Name:GORDON, JACOB L (MD, MS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:L
Last Name:GORDON
Suffix:
Gender:
Credentials:MD, MS
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3120 MARNAT RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-4503
Mailing Address - Country:US
Mailing Address - Phone:443-524-0965
Mailing Address - Fax:410-826-3780
Practice Address - Street 1:10 CROSSROADS DR STE 106
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5464
Practice Address - Country:US
Practice Address - Phone:443-524-0965
Practice Address - Fax:108-263-7804
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00883302084N0400X
MI43010772702084S0012X
PAMD4379802084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023686220002Medicaid
G13120Medicare UPIN