Provider Demographics
NPI:1174037899
Name:GIBSON, JERRY DEAN (MA, EDD LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DEAN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA, EDD LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5565
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-5565
Mailing Address - Country:US
Mailing Address - Phone:304-487-9996
Mailing Address - Fax:833-488-1901
Practice Address - Street 1:109 THORN ST STE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3571
Practice Address - Country:US
Practice Address - Phone:304-487-9996
Practice Address - Fax:833-488-1901
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2318101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional