Provider Demographics
NPI:1417495771
Name:GIBSON, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 SHEPPARD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-4205
Mailing Address - Country:US
Mailing Address - Phone:318-377-5436
Mailing Address - Fax:318-382-1190
Practice Address - Street 1:282 SHEPPARD ST
Practice Address - Street 2:SUITE B
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-4205
Practice Address - Country:US
Practice Address - Phone:318-377-5436
Practice Address - Fax:318-382-1190
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAHC0011912172V00000X
261QA0600X
LA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No172V00000XOther Service ProvidersCommunity Health Worker
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care