MEDICARE: MR. JAQUAN LAMONT GIBSON

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	376J00000X	Homemaker
2	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1063285609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAQUAN LAMONT GIBSON

Provider Business Mailing Address
First Line	:	2616 DENMARK RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4632
Country	:	US
Telephone Number	:	614-554-9172
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 DENMARK RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4632
Country	:	US
Telephone Number	:	614-554-9172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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Directions to “ MR. JAQUAN LAMONT GIBSON ” Practice Location

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