Provider Demographics
NPI:1518920495
Name:GIBSON, JARRED NATHANIAL (MS, ATC, CPED)
Entity Type:Individual
Prefix:MR
First Name:JARRED
Middle Name:NATHANIAL
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MS, ATC, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 COBURG RD STE 7
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5200
Mailing Address - Country:US
Mailing Address - Phone:541-654-9447
Mailing Address - Fax:541-972-2018
Practice Address - Street 1:1310 COBURG RD STE 7
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5200
Practice Address - Country:US
Practice Address - Phone:541-654-9447
Practice Address - Fax:541-972-2018
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-7308802255A2300X
224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty