Healthcare Provider Details

I. General information

NPI: 1457227779
Provider Name (Legal Business Name): JESSICA RAE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5148A MURFREESBORO RD
LA VERGNE TN
37086-1009
US

IV. Provider business mailing address

5148A MURFREESBORO RD
LA VERGNE TN
37086-1009
US

V. Phone/Fax

Practice location:
  • Phone: 615-213-2273
  • Fax: 615-213-2271
Mailing address:
  • Phone: 615-213-2273
  • Fax: 615-213-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number40060
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: