Healthcare Provider Details

I. General information

NPI: 1477462471
Provider Name (Legal Business Name): JENNIE GIPSON M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N DENEEN ST
STAUNTON IL
62088-1099
US

IV. Provider business mailing address

3865 RIDGE VIEW RD
EDWARDSVILLE IL
62025-7731
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-3838
  • Fax:
Mailing address:
  • Phone: 618-635-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146010137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: