Healthcare Provider Details

I. General information

NPI: 1598109811
Provider Name (Legal Business Name): JENNIFER LEE GORDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 05/13/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547
US

IV. Provider business mailing address

NMRTC OKINAWA, PSC 482, FPO AP 96362
FPO AP
96362
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-2778
  • Fax: 910-450-4452
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57540
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: