=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760909824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE JUNE GIBBS CDCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2017
-----------------------------------------------------
Last Update Date | 08/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 458 2ND AVE
-----------------------------------------------------
City | GALLIPOLIS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45631-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-446-2085
-----------------------------------------------------
Fax | 740-446-2292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 S 4TH ST
-----------------------------------------------------
City | IRONTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45638-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-532-3767
-----------------------------------------------------
Fax | 740-532-3385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 140838
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------