MEDICARE: MRS. JESSICA M GORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle	0501147343	IN

General Provider Information

NPI Number	:	1518359736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA M GORDON

Provider Business Mailing Address
First Line	:	4703 HIGHWOOD DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6067
Country	:	US
Telephone Number	:	260-797-3604
Fax Number	:

Provider Business Practice Location Address
First Line	:	4703 HIGHWOOD DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6067
Country	:	US
Telephone Number	:	260-797-3604
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	02/25/2015

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