Healthcare Provider Details

I. General information

NPI: 1104736008
Provider Name (Legal Business Name): JERRICA JOVAN NICOLE GIPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 SPORTS VILLAGE RD
FRISCO TX
75033-3505
US

IV. Provider business mailing address

6025 SPORTS VILLAGE RD
FRISCO TX
75033-3505
US

V. Phone/Fax

Practice location:
  • Phone: 214-687-9374
  • Fax:
Mailing address:
  • Phone: 214-687-9374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-449872
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: