Provider Demographics
NPI:1699219659
Name:GIBSON, WESLEY JAY (RD)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:JAY
Last Name:GIBSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S FL 32224
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-10
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered