Provider Demographics
NPI:1043324858
Name:GIBSON, JEAN H (PH D RN)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:H
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PH D RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 NORTHCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4439
Mailing Address - Country:US
Mailing Address - Phone:850-293-0975
Mailing Address - Fax:850-934-4744
Practice Address - Street 1:203 NORTHCLIFF DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4439
Practice Address - Country:US
Practice Address - Phone:850-293-0975
Practice Address - Fax:850-934-4744
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY004799103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59470Medicare ID - Type Unspecified