Provider Demographics
NPI:1487615027
Name:GORDON, JENNIFER (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CHIARAVALLOTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7500 HANOVER PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2011
Mailing Address - Country:US
Mailing Address - Phone:301-446-1644
Mailing Address - Fax:301-446-1647
Practice Address - Street 1:14999 HEALTH CENTER DR STE 201
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1087
Practice Address - Country:US
Practice Address - Phone:240-245-4245
Practice Address - Fax:240-245-4916
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD336407100Medicaid
MD239285YANQMedicare PIN