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General NPI Number Information
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NPI Number | 1477672095
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Entity Type | Individual
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Provider Name | JILL SUSANNE GIBSON P.T.
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Gender | Female
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 06/24/2014
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Provider Practice Location Address
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Address Line | 1570 E 17TH ST
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City | SANTA ANA
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State | CA
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Zip | 92705-8502
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Country | US
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Telephone | 714-834-1111
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Fax | 714-972-0454
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Provider Business Mailing Address
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Address Line | 6674 CORTE EDUARDO
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City | CARLSBAD
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State | CA
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Zip | 92009-4566
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Country | US
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Telephone | 805-931-4435
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT36639
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | P14505
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License Number State | NC
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