Provider Demographics
NPI:1407478464
Name:GIBSON, JESSICA (BC HAD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:BC HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11818 199TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3430
Mailing Address - Country:US
Mailing Address - Phone:337-274-3670
Mailing Address - Fax:
Practice Address - Street 1:1300 UNION TPKE STE 103A
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1759
Practice Address - Country:US
Practice Address - Phone:516-588-6742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000061292237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist