Healthcare Provider Details

I. General information

NPI: 1548754898
Provider Name (Legal Business Name): JESSICA GIBBONS LMSW, CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
JACKSON MI
49202-2179
US

IV. Provider business mailing address

1040 S WINTER ST STE 1022
ADRIAN MI
49221-3876
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801102670
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: