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NPI Code Detail

MEDICARE: JACQUELINE GORDON PSYD

MEDICARE: JACQUELINE GORDON PSYD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist01758MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1114923026
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELINE GORDON PSYD
Provider Business Mailing Address
First Line : 3800 S NATIONAL AVE STE 700
Second Line :
City : SPRINGFIELD
State : MO
Zip : 65807-5279
Country : US
Telephone Number : 417-269-8817
Fax Number : 417-269-8744
Provider Business Practice Location Address
First Line : 3800 S NATIONAL AVE STE 700
Second Line :
City : SPRINGFIELD
State : MO
Zip : 65807-5279
Country : US
Telephone Number : 417-269-8817
Fax Number : 417-269-8744
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/24/2005
Last Update Date : 01/12/2023

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