Provider Demographics
NPI:1396044129
Name:GIBSON, JESSICA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 FAIRWAYS DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-8256
Mailing Address - Country:US
Mailing Address - Phone:513-545-6642
Mailing Address - Fax:
Practice Address - Street 1:2945 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-8256
Practice Address - Country:US
Practice Address - Phone:513-545-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN143068164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN143068OtherOHIO BOARD OF NURSING