Provider Demographics
NPI:1194002162
Name:GIBSON, JENNIFER MAUREEN (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAUREEN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1578
Mailing Address - Country:US
Mailing Address - Phone:740-532-4858
Mailing Address - Fax:740-532-4859
Practice Address - Street 1:1408 CAMPBELL DR STE 200
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2301
Practice Address - Country:US
Practice Address - Phone:740-534-9202
Practice Address - Fax:740-532-4777
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV68316363LF0000X
OHNP13208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021896Medicaid
OH0057626Medicaid
KY7100184340Medicaid