Healthcare Provider Details

I. General information

NPI: 1053645390
Provider Name (Legal Business Name): JENNIFER LEE GIBBS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 MEDINA RD SUITE 220
MEDINA OH
44256-9654
US

IV. Provider business mailing address

150 N MILLER RD BLDG. 150A
FAIRLAWN OH
44333-3770
US

V. Phone/Fax

Practice location:
  • Phone: 330-952-0403
  • Fax: 330-952-0826
Mailing address:
  • Phone: 330-867-2240
  • Fax: 330-867-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP9232
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: