Provider Demographics
NPI:1396002333
Name:GIBSON, JAMIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 W KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5930
Mailing Address - Country:US
Mailing Address - Phone:870-495-2911
Mailing Address - Fax:870-495-2912
Practice Address - Street 1:723 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5930
Practice Address - Country:US
Practice Address - Phone:870-495-2911
Practice Address - Fax:870-495-2912
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0904022101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AD45OtherBCBS
AR171638795Medicaid