Healthcare Provider Details

I. General information

NPI: 1417495771
Provider Name (Legal Business Name): JONATHAN GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 SHEPPARD ST SUITE B
MINDEN LA
71055-4205
US

IV. Provider business mailing address

282 SHEPPARD ST SUITE B
MINDEN LA
71055-4205
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-5436
  • Fax: 318-382-1190
Mailing address:
  • Phone: 318-377-5436
  • Fax: 318-382-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberHC0011912
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: