Healthcare Provider Details

I. General information

NPI: 1013971605
Provider Name (Legal Business Name): JACQUELYN H GIBBONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 10/26/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRANITE DR SUITE 200
MEDIA PA
19063-5134
US

IV. Provider business mailing address

100 GRANITE DR SUITE 200
MEDIA PA
19063-5134
US

V. Phone/Fax

Practice location:
  • Phone: 610-565-1945
  • Fax: 610-892-7848
Mailing address:
  • Phone: 610-565-1945
  • Fax: 610-892-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD006608E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0764795
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: