Provider Demographics
NPI:1952507345
Name:GIBBON, JEREMY ELDON
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ELDON
Last Name:GIBBON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SE 12TH AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2592
Mailing Address - Country:US
Mailing Address - Phone:503-475-3373
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor