Provider Demographics
NPI:1144577529
Name:GIBSON, JACOB (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11607 LAMPTON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7898
Mailing Address - Country:US
Mailing Address - Phone:801-301-2450
Mailing Address - Fax:
Practice Address - Street 1:11607 LAMPTON VIEW DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-7898
Practice Address - Country:US
Practice Address - Phone:801-301-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5642816-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist