Provider Demographics
NPI:1164544839
Name:GIBSON, JENNIFER L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 N BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1610
Mailing Address - Country:US
Mailing Address - Phone:312-316-5551
Mailing Address - Fax:
Practice Address - Street 1:2650 W MONTROSE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1560
Practice Address - Country:US
Practice Address - Phone:872-205-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007651103TC0700X, 103TB0200X, 103TC2200X, 103TF0000X
IL071007651103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily