Healthcare Provider Details

I. General information

NPI: 1639353436
Provider Name (Legal Business Name): JANE CHANDLER GIBBONS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9137 OLD BONHOMME RD
OLIVETTE MO
63132-4417
US

IV. Provider business mailing address

9137 OLD BONHOMME RD
OLIVETTE MO
63132-4417
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-7002
  • Fax: 314-997-6848
Mailing address:
  • Phone: 314-997-7002
  • Fax: 314-997-6848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number2003006010
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: