MEDICARE: JACQUELINE 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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1144663089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE GIBBONS

Provider Business Mailing Address
First Line	:	3799 CAPE LANDING CIR APT C
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-1123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3799 CAPE LANDING CIR APT C
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-1123
Country	:	US
Telephone Number	:	845-313-2012
Fax Number	:

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

Provider Enumeration Date	:	04/10/2013
Last Update Date	:	07/25/2022

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Directions to “ JACQUELINE GIBBONS ” Practice Location

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