Provider Demographics
NPI:1811053093
Name:GIBAUD, JONATHA (PH,D)
Entity type:Individual
Prefix:DR
First Name:JONATHA
Middle Name:
Last Name:GIBAUD
Suffix:
Gender:F
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6726 PENNYWELL DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-3010
Mailing Address - Country:US
Mailing Address - Phone:615-356-5696
Mailing Address - Fax:
Practice Address - Street 1:6726 PENNYWELL DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-3010
Practice Address - Country:US
Practice Address - Phone:615-356-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP578103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3683837Medicare ID - Type Unspecified