Provider Demographics
NPI:1831422112
Name:GIBSON OF JAX, INC.
Entity type:Organization
Organization Name:GIBSON OF JAX, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:WOODY
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:904-254-0337
Mailing Address - Street 1:3775 CRICKET COVE RD E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-8401
Mailing Address - Country:US
Mailing Address - Phone:904-254-0337
Mailing Address - Fax:904-223-4368
Practice Address - Street 1:3775 CRICKET COVE RD E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-8401
Practice Address - Country:US
Practice Address - Phone:904-254-0337
Practice Address - Fax:904-223-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 5525235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356441828OtherINDIVIDUAL NPI
FL885295200Medicaid