Provider Demographics
NPI:1497089361
Name:GIBSON, JACQUELINE (MA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1542
Mailing Address - Street 2:
Mailing Address - City:WESTWEGO
Mailing Address - State:LA
Mailing Address - Zip Code:70096-1542
Mailing Address - Country:US
Mailing Address - Phone:504-460-0096
Mailing Address - Fax:
Practice Address - Street 1:1904 ORMOND BLVD STE 201
Practice Address - Street 2:
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-3829
Practice Address - Country:US
Practice Address - Phone:504-388-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist