MEDICARE: JENNIFER GIBSON, PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071007651	IL

General Provider Information

NPI Number	:	1003211426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER GIBSON, PSYD

Provider Business Mailing Address
First Line	:	4334 N BELL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1610
Country	:	US
Telephone Number	:	312-316-5551
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 W MONTROSE AVE
Second Line	:	SUITE 200
City	:	CHICAGO
State	:	IL
Zip	:	60618-1560
Country	:	US
Telephone Number	:	872-205-6110
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL PSYCHOLOGIST
Name	:	DR. JENNIFER GIBSON
Credential	:	PSYD
Telephone Number	:	312-316-5551

Provider Enumeration Date	:	10/28/2014
Last Update Date	:	10/28/2014

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