Basic Information
| Provider Information | |||||||||
| NPI: | 1679666861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1419 CHATTANOOGA AVE | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062594435 | ||||||||
| FaxNumber: | 7062262283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062594435 | ||||||||
| FaxNumber: | 7062262283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN047297 | GA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 000487341B | 05 | GA | MEDICAID |