Healthcare Provider Details

I. General information

NPI: 1073553376
Provider Name (Legal Business Name): JILL R GIBSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE SUITE 4150
GRAND RAPIDS MI
49503-2514
US

IV. Provider business mailing address

15448 HOWARD ST
SPRING LAKE MI
49456-1526
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2100
  • Fax: 616-267-2101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704165794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: