Provider Demographics
NPI:1376289751
Name:GIBSON, JENNIE (OTR/L, CSRS, CNS)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OTR/L, CSRS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S PEPPERTREE DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3208
Mailing Address - Country:US
Mailing Address - Phone:334-559-3820
Mailing Address - Fax:
Practice Address - Street 1:3875 E WILLIAMS FIELD RD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8700
Practice Address - Country:US
Practice Address - Phone:480-704-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XN1300X
AZOTH-008529225XN1300X
AL4698225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist