Provider Demographics
NPI:1538948880
Name:GORDON, KESHA M (CPT, BLSI)
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:CPT, BLSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4553 REVELSTOKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-7430
Mailing Address - Country:US
Mailing Address - Phone:904-383-6915
Mailing Address - Fax:
Practice Address - Street 1:1301 MONUMENT RD STE 17
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6462
Practice Address - Country:US
Practice Address - Phone:904-383-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL641008180001246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy