Healthcare Provider Details

I. General information

NPI: 1619793015
Provider Name (Legal Business Name): JACOB GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 CANVASBACK LN
COLUMBUS OH
43215-7023
US

IV. Provider business mailing address

1656 CANVASBACK LN
COLUMBUS OH
43215-7023
US

V. Phone/Fax

Practice location:
  • Phone: 419-270-6893
  • Fax:
Mailing address:
  • Phone: 419-270-6893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberUR685742
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberUR685742
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: