=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104619543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GIBSON DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2025
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3964 GOODMAN RD E STE 105
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-8711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-932-4625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 SPRINGWALK RD
-----------------------------------------------------
City | COLDWATER
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38618-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-598-4084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT7954
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------