Provider Demographics
NPI:1295204667
Name:GIPSON, JAMAL D
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:D
Last Name:GIPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6156
Mailing Address - Country:US
Mailing Address - Phone:318-340-1535
Mailing Address - Fax:318-340-1539
Practice Address - Street 1:4951 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-6156
Practice Address - Country:US
Practice Address - Phone:318-340-1535
Practice Address - Fax:318-340-1539
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8801101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health