Healthcare Provider Details

I. General information

NPI: 1376289751
Provider Name (Legal Business Name): JENNIE GIBSON OTR/L, CSRS, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 E WILLIAMS FIELD RD STE 201
GILBERT AZ
85295-8700
US

IV. Provider business mailing address

611 S PEPPERTREE DR
GILBERT AZ
85296-3208
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-5954
  • Fax:
Mailing address:
  • Phone: 334-559-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4698
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOTH-008529
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: