Provider Demographics
NPI:1558876581
Name:GIBSON, SHERITA DAWN
Entity Type:Individual
Prefix:
First Name:SHERITA
Middle Name:DAWN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHERITA
Other - Middle Name:D
Other - Last Name:GIBSON-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3621 N KELLEY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-4520
Mailing Address - Country:US
Mailing Address - Phone:405-524-5525
Mailing Address - Fax:405-524-5528
Practice Address - Street 1:3621 N KELLEY AVE STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:405-524-5528
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)