Provider Demographics
NPI:1770989220
Name:GIBB, JENNIFER (APN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GIBB
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 KAITLYN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3487
Mailing Address - Country:US
Mailing Address - Phone:309-261-1102
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1612
Practice Address - Country:US
Practice Address - Phone:309-261-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011788363LF0000X
IL277.000965363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily