MEDICARE: DR.JACKIEGILBERTSONLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	276	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124383435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR.JACKIEGILBERTSONLLC

Provider Business Mailing Address
First Line	:	623 QUINCY ST
Second Line	:	102
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8231
Country	:	US
Telephone Number	:	605-430-6364
Fax Number	:	605-716-9491

Provider Business Practice Location Address
First Line	:	623 QUINCY ST
Second Line	:	102
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8231
Country	:	US
Telephone Number	:	605-430-6364
Fax Number	:	605-716-9491

Authorized Official
Title or Position	:	PSYCHOLOGISTLICENSED
Name	:	DR. JACKIE R GILBERTSON
Credential	:	ED.D
Telephone Number	:	605-430-6364

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	07/12/2012

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