Healthcare Provider Details

I. General information

NPI: 1639352784
Provider Name (Legal Business Name): MICHELLE J. GIBSON, MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5440 WATKINS DR SUITE B
JACKSON MS
39206-2034
US

IV. Provider business mailing address

5440 WATKINS DR SUITE B
JACKSON MS
39206-2034
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-2726
  • Fax: 601-364-2731
Mailing address:
  • Phone: 601-364-2726
  • Fax: 601-364-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number15752
License Number StateMS

VIII. Authorized Official

Name: DR. MICHELLE JEANETTE GIBSON
Title or Position: OWNER
Credential: MD
Phone: 601-364-2726