Healthcare Provider Details

I. General information

NPI: 1417122649
Provider Name (Legal Business Name): JESSICA ELIZABETH GIBSON M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 RIVERFRONT DR
LITTLE ROCK AR
72202
US

IV. Provider business mailing address

24 AVIGNON CT
LITTLE ROCK AR
72223-9104
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-6965
  • Fax: 501-603-0675
Mailing address:
  • Phone: 501-351-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP#2586
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: