1285415356 NPI number — MRS. JACQUELINE F GIBSON

Table of content: MRS. JACQUELINE F GIBSON (NPI 1285415356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285415356 NPI number — MRS. JACQUELINE F GIBSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
JACQUELINE
Provider Middle Name:
F
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285415356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 MAPLE CREEK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-2499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-460-5370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4710 BELLAIRE BLVD STE 175
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLAIRE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77401-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
346-356-3060
Provider Business Practice Location Address Fax Number:
713-790-6313
Provider Enumeration Date:
10/13/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP145251 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)