Provider Demographics
NPI:1043488562
Name:GIBBONS, JAKE (OTA)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-1024
Mailing Address - Country:US
Mailing Address - Phone:615-896-6400
Mailing Address - Fax:615-896-5177
Practice Address - Street 1:326 SUMMERSET ST
Practice Address - Street 2:
Practice Address - City:FONTANELLE
Practice Address - State:IA
Practice Address - Zip Code:50846-8098
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:615-896-5177
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00306224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant