Provider Demographics
NPI:1275034167
Name:GIBSON, JASON WILDE (PT, AT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WILDE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45057 GOV BRADFORD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3713
Mailing Address - Country:US
Mailing Address - Phone:248-561-1440
Mailing Address - Fax:
Practice Address - Street 1:7800 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3461
Practice Address - Country:US
Practice Address - Phone:313-543-6295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist