Provider Demographics
NPI:1740860105
Name:GIBSON, JADE ALEXA (RD)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:ALEXA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8216 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-2213
Mailing Address - Country:US
Mailing Address - Phone:515-480-3246
Mailing Address - Fax:
Practice Address - Street 1:6155 OAK ST STE C
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64113-2266
Practice Address - Country:US
Practice Address - Phone:515-480-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered