Provider Demographics
NPI:1932873353
Name:GIBBS, JESSICA RENEE (MA, EDS, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RENEE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MA, EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 N ROADRUNNER PKWY APT 904
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8119
Mailing Address - Country:US
Mailing Address - Phone:575-499-4002
Mailing Address - Fax:
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1243
Practice Address - Country:US
Practice Address - Phone:575-527-5884
Practice Address - Fax:575-527-5886
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM369195103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool