Provider Demographics
NPI:1417701707
Name:GORDON, JADE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
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 1:108 N 2ND ST APT A
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2590
Mailing Address - Country:US
Mailing Address - Phone:406-201-9213
Mailing Address - Fax:406-215-9002
Practice Address - Street 1:108 N 2ND ST APT A
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2590
Practice Address - Country:US
Practice Address - Phone:406-201-9213
Practice Address - Fax:406-215-9002
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-LTD-LIC-294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist