Provider Demographics
NPI:1417122649
Name:GIBSON, JESSICA ELIZABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 AVIGNON CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9104
Mailing Address - Country:US
Mailing Address - Phone:501-351-5127
Mailing Address - Fax:
Practice Address - Street 1:1600 RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202
Practice Address - Country:US
Practice Address - Phone:501-663-6965
Practice Address - Fax:501-603-0675
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2586235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113694335OtherTRICARE
AR168616721Medicaid