Healthcare Provider Details

I. General information

NPI: 1750967378
Provider Name (Legal Business Name): JESSICA KAYLA GORDON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST STE 3
MANNING SC
29102-3149
US

IV. Provider business mailing address

50 E HOSPITAL ST STE 3
MANNING SC
29102-3149
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-8828
  • Fax:
Mailing address:
  • Phone: 803-435-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberV0405
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL83656
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: