Provider Demographics
NPI:1992117618
Name:GORDON, JENNIFER (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1681
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1681
Mailing Address - Country:US
Mailing Address - Phone:229-226-4114
Mailing Address - Fax:229-226-6480
Practice Address - Street 1:311 N DAWSON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5132
Practice Address - Country:US
Practice Address - Phone:229-226-4114
Practice Address - Fax:229-226-6480
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001408225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA001408OtherGA LICENSE NUMBER