Individual
JACOB GORDON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1656 CANVASBACK LN, COLUMBUS, OH 43215-7023
(419) 270-6893
Mailing address
1656 CANVASBACK LN, COLUMBUS, OH 43215-7023
(419) 270-6893
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
UR685742
OH
347C00000X
Private Vehicle
UR685742
OH
385HR2060X
Child Intellectual and/or Developmental Disabilities Respite Care
Primary
—
—
Other
Enumeration date
12/02/2024
Last updated
12/02/2024
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