Provider Demographics
NPI:1760551568
Name:GIBBONS, JACQUELINE B (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:B
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1749
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-1749
Mailing Address - Country:US
Mailing Address - Phone:910-295-6868
Mailing Address - Fax:910-295-1514
Practice Address - Street 1:ONE PAGE ROAD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-6868
Practice Address - Fax:910-295-1514
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8092235Z00000X
SC772363AS0400X
NC0010-01257363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist