Healthcare Provider Details

I. General information

NPI: 1477345692
Provider Name (Legal Business Name): OLIVIA JORDAN GIPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 7TH ST
PORT HURON MI
48060-5324
US

IV. Provider business mailing address

6417 SMITHS CREEK RD
KIMBALL MI
48074-3614
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-9118
  • Fax:
Mailing address:
  • Phone: 248-952-4261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: