Healthcare Provider Details

I. General information

NPI: 1427387380
Provider Name (Legal Business Name): JENNIFER M GIBBS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 NW MULHOLLAND DR
ROSEBURG OR
97470
US

IV. Provider business mailing address

5255 TYEE RD
UMPQUA OR
97486-9723
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-5795
  • Fax: 423-602-2028
Mailing address:
  • Phone: 541-817-6848
  • Fax: 541-767-2751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number26087
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3255
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: