Provider Demographics
NPI:1962447540
Name:GILBERT, JACQUELYN DENISE (PT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:DENISE
Last Name:GILBERT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2418
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-2418
Mailing Address - Country:US
Mailing Address - Phone:870-792-7868
Mailing Address - Fax:870-792-7868
Practice Address - Street 1:1605 2ND ST
Practice Address - Street 2:
Practice Address - City:EARLE
Practice Address - State:AR
Practice Address - Zip Code:72331-1634
Practice Address - Country:US
Practice Address - Phone:870-792-7868
Practice Address - Fax:870-792-7868
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y960OtherMEDICARE PTAN
AR154842721Medicaid