Provider Demographics
NPI:1891212072
Name:GIBSON, JACOB LEE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LEE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 COLUMBIA TRL
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-5530
Mailing Address - Country:US
Mailing Address - Phone:513-703-8148
Mailing Address - Fax:
Practice Address - Street 1:8412 OLD TROY PIKE
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1030
Practice Address - Country:US
Practice Address - Phone:937-235-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT017168208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPT017168OtherPHYSICAL THERAPY LICENSE