Provider Demographics
NPI:1942742341
Name:GIBSON, JORDAN (BCBA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 KAMOKILA BLVD STE 133
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2097
Mailing Address - Country:US
Mailing Address - Phone:808-800-1195
Mailing Address - Fax:
Practice Address - Street 1:1001 KAMOKILA BLVD STE 133
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2097
Practice Address - Country:US
Practice Address - Phone:808-800-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-16-25760106S00000X
HIBA-301103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician