Provider Demographics
NPI:1093803314
Name:GIBSON, JIMMY R (LISW)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:575-628-0676
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5896
Practice Address - Country:US
Practice Address - Phone:575-885-0956
Practice Address - Fax:575-234-9854
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-076731041C0700X
KY15441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000375385OtherANTHEM BC/BS
KY1164437OtherCHA HEALTH
KY611549000OtherACS-DEPT OF LABOR
KY0675525Medicare ID - Type Unspecified
KY611549000OtherACS-DEPT OF LABOR
KY0366431Medicare ID - Type Unspecified
KY1266964Medicare ID - Type Unspecified
KY0371326Medicare ID - Type Unspecified
KY0653326Medicare ID - Type Unspecified
KY0675425Medicare ID - Type Unspecified
KY000000375385OtherANTHEM BC/BS
KY0675625Medicare ID - Type Unspecified