Provider Demographics
NPI:1922548114
Name:GIBSON, JZSA-JAZA
Entity Type:Individual
Prefix:
First Name:JZSA-JAZA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 S WEST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2957
Mailing Address - Country:US
Mailing Address - Phone:517-879-7434
Mailing Address - Fax:
Practice Address - Street 1:1102 S WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-2957
Practice Address - Country:US
Practice Address - Phone:517-879-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327522163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse