=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083317747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JEAN MARIE GIBBS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2023
-----------------------------------------------------
Last Update Date | 03/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 N MILL ST
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-6304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-389-1419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2250 MARGARET DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60538-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-373-5298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------