Healthcare Provider Details

I. General information

NPI: 1760299846
Provider Name (Legal Business Name): JESSICA GORDON RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA GOODMAN RNFA

II. Dates (important events)

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

III. Provider practice location address

8591 S BROADWAY AVE
TYLER TX
75703-5470
US

IV. Provider business mailing address

8591 S BROADWAY AVE
TYLER TX
75703-5470
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-9173
  • Fax:
Mailing address:
  • Phone: 903-592-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number756983
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: