1598109811 NPI number — JENNIFER LEE GORDON MD

Table of content: JENNIFER LEE GORDON MD (NPI 1598109811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598109811 NPI number — JENNIFER LEE GORDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
JENNIFER
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598109811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NMRTC OKINAWA, PSC 482, FPO AP 96362
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FPO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BREWSTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP LEJEUNE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-449-2778
Provider Business Practice Location Address Fax Number:
910-450-4452
Provider Enumeration Date:
04/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 57540 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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