Provider Demographics
NPI:1437393824
Name:GIBB, JAMES PAUL
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PAUL
Last Name:GIBB
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 1:2619 W HEADING AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-4971
Mailing Address - Country:US
Mailing Address - Phone:217-248-0854
Mailing Address - Fax:
Practice Address - Street 1:2619 W HEADING AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-4971
Practice Address - Country:US
Practice Address - Phone:309-966-2989
Practice Address - Fax:309-966-4560
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional