Healthcare Provider Details

I. General information

NPI: 1639870918
Provider Name (Legal Business Name): JAMIE GORDON WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 S 5TH AVE
DENTON MD
21629-1380
US

IV. Provider business mailing address

506 S 5TH AVE
DENTON MD
21629-1380
US

V. Phone/Fax

Practice location:
  • Phone: 410-924-0730
  • Fax:
Mailing address:
  • Phone: 443-493-7575
  • Fax: 443-493-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR230295
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberLH-0010272
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: