Basic Information
| Provider Information | |||||||||
| NPI: | 1114029550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| Address2: | 9040 JACKSON AVENUE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539686478 | ||||||||
| FaxNumber: | 2539689054 | ||||||||
| Practice Location | |||||||||
| Address1: | 9040 JACKSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539686478 | ||||||||
| FaxNumber: | 2539689054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301077270 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | 4301077270 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084S0012X | MD437980 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | MD437980 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1023686220002 | 05 | PA | MEDICAID |