Provider Demographics
NPI:1710565429
Name:GIBBS, ZACKERY J
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:J
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 POWELL LN APT 5
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139-1643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1724 S 3RD ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2269
Practice Address - Country:US
Practice Address - Phone:740-479-5135
Practice Address - Fax:740-237-4870
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.177308101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0448817Medicaid