Provider Demographics
NPI:1144216615
Name:GIBSON, JACQUELINE M (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 DUNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548
Mailing Address - Country:US
Mailing Address - Phone:850-267-2001
Mailing Address - Fax:
Practice Address - Street 1:3686 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-8463
Practice Address - Country:US
Practice Address - Phone:850-892-8045
Practice Address - Fax:850-892-8039
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health