Provider Demographics
NPI:1740579820
Name:GIBSON, JONATHAN THOMAS
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:THOMAS
Last Name:GIBSON
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 1:1247 RICKERT DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540
Mailing Address - Country:US
Mailing Address - Phone:630-357-7979
Mailing Address - Fax:630-357-1047
Practice Address - Street 1:1247 RICKERT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-1008
Practice Address - Country:US
Practice Address - Phone:630-357-7979
Practice Address - Fax:630-357-1047
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.134945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine