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NPI Code Detail

MEDICARE: JACQUELINE M GIBSON LMHC

MEDICARE: JACQUELINE M GIBSON LMHC
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
1101YM0800XMental Health CounselorMH4668FL

General Provider Information

NPI Number : 1144216615
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELINE M GIBSON LMHC
Provider Business Mailing Address
First Line : 73 DUNE DRIVE
Second Line :
City : SANTA ROSA BEACH
State : FL
Zip : 32548
Country : US
Telephone Number : 850-267-2001
Fax Number :
Provider Business Practice Location Address
First Line : 3686 US HIGHWAY 331 S
Second Line :
City : DEFUNIAK SPRINGS
State : FL
Zip : 32435-8463
Country : US
Telephone Number : 850-892-8045
Fax Number : 850-892-8039
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2005
Last Update Date : 07/08/2007

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