=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376289751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIE GIBSON OTR/L, CSRS, CNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2022
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3875 E WILLIAMS FIELD RD STE 201
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-704-5954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 S PEPPERTREE DR
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-559-3820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XN1300X
-----------------------------------------------------
Taxonomy Name | Neurorehabilitation Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XN1300X
-----------------------------------------------------
Taxonomy Name | Neurorehabilitation Occupational Therapist
-----------------------------------------------------
License Number | OTH-008529
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 4698
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------