1255424958 NPI number — MRS. JANET WILKE GIBSON MA, MFT

Table of content: MRS. JANET WILKE GIBSON MA, MFT (NPI 1255424958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255424958 NPI number — MRS. JANET WILKE GIBSON MA, MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
JANET
Provider Middle Name:
WILKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, MFT
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:
1255424958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 BAKER ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-269-7977
Provider Business Mailing Address Fax Number:
612-395-5602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 BAKER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-269-7977
Provider Business Practice Location Address Fax Number:
612-395-5602
Provider Enumeration Date:
10/02/2006

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: 106H00000X , with the licence number:  MFT895 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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