Provider Demographics
NPI:1477128080
Name:GIBSON, JODIE (DC)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27765 KLAUS CT
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94542-2366
Mailing Address - Country:US
Mailing Address - Phone:870-273-5520
Mailing Address - Fax:
Practice Address - Street 1:27765 KLAUS CT
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-2366
Practice Address - Country:US
Practice Address - Phone:870-273-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35057111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor