Healthcare Provider Details

I. General information

NPI: 1619843828
Provider Name (Legal Business Name): JAMES K GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAKE GIBSON

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 HERON DR NW APT 203I
GRAND RAPIDS MI
49534-1627
US

IV. Provider business mailing address

74 HERON DR NW APT 203I
GRAND RAPIDS MI
49534-1627
US

V. Phone/Fax

Practice location:
  • Phone: 231-833-0569
  • Fax:
Mailing address:
  • Phone: 231-833-0569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: