Healthcare Provider Details

I. General information

NPI: 1720774391
Provider Name (Legal Business Name): JESSICA L GIBBONS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L ROLAND

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 SW 4TH AVE
ONTARIO OR
97914-1851
US

IV. Provider business mailing address

1441 NE 10TH AVE
PAYETTE ID
83661-5420
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2340
  • Fax: 541-889-2593
Mailing address:
  • Phone: 208-642-9376
  • Fax: 208-642-9279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1671830
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO229715
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: