Healthcare Provider Details

I. General information

NPI: 1073276275
Provider Name (Legal Business Name): JADYN BROOKE GIBBS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CHUKKA HINA
DURANT OK
74701-7117
US

IV. Provider business mailing address

3500 LAZY LN
DURANT OK
74701-6307
US

V. Phone/Fax

Practice location:
  • Phone: 580-920-2100
  • Fax: 580-916-9201
Mailing address:
  • Phone: 580-743-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2681
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: