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General NPI Number Information
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NPI Number | 1831422112
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Entity Type | Organization
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Legal Business Name | GIBSON OF JAX, INC.
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Dates
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Enumeration Date | 09/17/2009
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Last Update Date | 09/17/2009
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Provider Practice Location Address
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Address Line | 3775 CRICKET COVE RD E
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City | JACKSONVILLE
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State | FL
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Zip | 32224-8401
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Country | US
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Telephone | 904-254-0337
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Fax | 904-223-4368
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Provider Business Mailing Address
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Address Line | 3775 CRICKET COVE RD E
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City | JACKSONVILLE
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State | FL
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Zip | 32224-8401
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Country | US
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Telephone | 904-254-0337
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Fax | 904-223-4368
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. KATHERINE WOODY GIBSON
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Credential | MA, CCC-SLP
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Telephone | 904-254-0337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA 5525
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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