1477672095 NPI number — MRS. JILL SUSANNE GIBSON P.T.

Table of content: MRS. JILL SUSANNE GIBSON P.T. (NPI 1477672095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477672095 NPI number — MRS. JILL SUSANNE GIBSON P.T.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON
Provider Other First Name:
JILL
Provider Other Middle Name:
SUSANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477672095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6674 CORTE EDUARDO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92009-4566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-931-4435
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 E 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-8502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-834-1111
Provider Business Practice Location Address Fax Number:
714-972-0454
Provider Enumeration Date:
03/28/2007

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:  PT36639 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: P14505 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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