Provider Demographics
NPI:1730166257
Name:GORHAM, JENNIE L (DO)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:GORHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:
Practice Address - Street 1:3555 S NATIONAL AVE
Practice Address - Street 2:#302
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-6868
Practice Address - Fax:417-269-6865
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO100997208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730166257Medicaid
G38111Medicare UPIN
MO1730166257Medicaid
019012629Medicare ID - Type Unspecified