Provider Demographics
NPI:1730670506
Name:GIBBS, JEWELL MIRIAM (LPC)
Entity Type:Individual
Prefix:MS
First Name:JEWELL
Middle Name:MIRIAM
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 CHURCH ST NE STE 208
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4734
Mailing Address - Country:US
Mailing Address - Phone:703-570-4104
Mailing Address - Fax:
Practice Address - Street 1:501 CHURCH ST NE STE 208
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4734
Practice Address - Country:US
Practice Address - Phone:703-570-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional