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General NPI Number Information
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NPI Number | 1669574174
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Entity Type | Individual
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Provider Name | JENNIFER ANN GIBBARD MOTR/L
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Gender | Female
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Dates
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Enumeration Date | 09/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 510 E 17TH ST # 400
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6154
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Country | US
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Telephone | 208-589-4365
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Fax |
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Provider Business Mailing Address
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Address Line | 4573 TRANQUIL PL
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City | AMMON
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State | ID
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Zip | 83406-5005
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Country | US
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Telephone |
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-785
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License Number State | ID
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