Provider Demographics
NPI:1124762026
Name:GORDNER, JACOB SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:SAMUEL
Last Name:GORDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103-182 PRINCESS ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:ON
Mailing Address - Zip Code:K7L 1B1
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2296
Practice Address - Country:US
Practice Address - Phone:650-725-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA175900390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program