Provider Demographics
NPI:1831309723
Name:GILBERTSON, JEFFERY B (M DIV)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:B
Last Name:GILBERTSON
Suffix:
Gender:M
Credentials:M DIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7602 PARK PLACE CIR
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-7540
Mailing Address - Country:US
Mailing Address - Phone:502-241-3129
Mailing Address - Fax:
Practice Address - Street 1:1203 WATTERSON TRL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2329
Practice Address - Country:US
Practice Address - Phone:502-253-8425
Practice Address - Fax:502-253-8433
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-06-035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist