Provider Demographics
NPI:1770770810
Name:GIBBONS, JENNIFER DAINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAINE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9675 MIGNONETTE ST
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5027
Mailing Address - Country:US
Mailing Address - Phone:909-636-1788
Mailing Address - Fax:
Practice Address - Street 1:11776 MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1622
Practice Address - Country:US
Practice Address - Phone:760-956-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)