MEDICARE: JESSICA GIBBONS

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1104786391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GIBBONS

Provider Business Mailing Address
First Line	:	28 PEACH TREE LN
Second Line	:
City	:	BERLIN
State	:	CT
Zip	:	06037-2260
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 PEACH TREE LN
Second Line	:
City	:	BERLIN
State	:	CT
Zip	:	06037-2260
Country	:	US
Telephone Number	:	203-312-3939
Fax Number	:

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

Provider Enumeration Date	:	11/12/2025
Last Update Date	:	11/12/2025

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