Healthcare Provider Details

I. General information

NPI: 1770132136
Provider Name (Legal Business Name): JANICE L GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLOMA WAY
ROSEVILLE CA
95661-4480
US

IV. Provider business mailing address

14264 NOJACK CT
PENN VALLEY CA
95946-9731
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-6647
  • Fax:
Mailing address:
  • Phone: 530-615-9995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number33828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: