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General NPI Number Information
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NPI Number | 1417495771
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Entity Type | Individual
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Provider Name | JONATHAN GIBSON
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Gender | Male
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Dates
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Enumeration Date | 02/07/2017
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Last Update Date | 04/20/2023
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Provider Practice Location Address
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Address Line | 282 SHEPPARD ST SUITE B
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City | MINDEN
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State | LA
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Zip | 71055-4205
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Country | US
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Telephone | 318-377-5436
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Fax | 318-382-1190
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Provider Business Mailing Address
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Address Line | 282 SHEPPARD ST SUITE B
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City | MINDEN
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State | LA
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Zip | 71055-4205
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Country | US
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Telephone | 318-377-5436
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Fax | 318-382-1190
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | HC0011912
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | LA
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