1124446364 NPI number — MRS. JESSICA N GIBSON PT, DPT

Table of content: MRS. JESSICA N GIBSON PT, DPT (NPI 1124446364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124446364 NPI number — MRS. JESSICA N GIBSON PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
JESSICA
Provider Middle Name:
N
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STURDIVANT
Provider Other First Name:
JESSICA
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124446364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 STURBRIDGE DR
Provider Second Line Business Mailing Address:
GEORGETOWN
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40324-2536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-424-7137
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 WINDSOR PATH STE 1
Provider Second Line Business Practice Location Address:
GEORGETOWN
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-9617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-570-2337
Provider Business Practice Location Address Fax Number:
502-570-2338
Provider Enumeration Date:
04/04/2014

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: 225100000X , with the licence number:  005483 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000869196 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100300660 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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