Healthcare Provider Details

I. General information

NPI: 1962311134
Provider Name (Legal Business Name): JASON MICHAEL GORDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23072 LAKE CENTER DR STE 115
LAKE FOREST CA
92630-2880
US

IV. Provider business mailing address

5931 LOS FELIZ DR
BUENA PARK CA
90620-3426
US

V. Phone/Fax

Practice location:
  • Phone: 949-406-9690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-EILYAU
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: