Provider Demographics
NPI:1215145222
Name:GORDON, JESSICA E (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 HIGHWAY 39 N
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301
Mailing Address - Country:US
Mailing Address - Phone:601-483-6211
Mailing Address - Fax:601-482-3623
Practice Address - Street 1:5000 HIGHWAY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-483-6211
Practice Address - Fax:601-482-3263
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS198212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06527227Medicaid
302I265596Medicare Oscar/Certification