Healthcare Provider Details

I. General information

NPI: 1497355481
Provider Name (Legal Business Name): JESSIE ANN GIBSON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 WELDON CT SW
ALBANY OR
97321-3759
US

IV. Provider business mailing address

6224 WELDON CT SW
ALBANY OR
97321-3759
US

V. Phone/Fax

Practice location:
  • Phone: 740-294-7810
  • Fax:
Mailing address:
  • Phone: 740-294-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDIET.DI.70103414
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86105106
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number59.003166
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10258537
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number11340
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: