Healthcare Provider Details

I. General information

NPI: 1063285609
Provider Name (Legal Business Name): MR. JAQUAN LAMONT GIBSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 DENMARK RD
COLUMBUS OH
43232-4632
US

IV. Provider business mailing address

2616 DENMARK RD
COLUMBUS OH
43232-4632
US

V. Phone/Fax

Practice location:
  • Phone: 614-554-9172
  • Fax:
Mailing address:
  • Phone: 614-554-9172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: