Provider Demographics
NPI:1407087885
Name:GIBSON, JENNIFER LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2302 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3244
Mailing Address - Country:US
Mailing Address - Phone:270-415-5080
Mailing Address - Fax:270-415-5071
Practice Address - Street 1:2302 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3244
Practice Address - Country:US
Practice Address - Phone:270-415-5080
Practice Address - Fax:270-415-5071
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1780DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist