Provider Demographics
NPI:1477672095
Name:GIBSON, JILL SUSANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SUSANNE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:SUSANNE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6674 CORTE EDUARDO
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-4566
Mailing Address - Country:US
Mailing Address - Phone:805-931-4435
Mailing Address - Fax:
Practice Address - Street 1:1570 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8502
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:714-972-0454
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36639225100000X
NCP14505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist