Provider Demographics
NPI:1699276162
Name:GORDON, JILL ANN (RT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 GLYNN ADDY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 GLYNN ADDY DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6471
Practice Address - Country:US
Practice Address - Phone:404-304-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6382227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified