MEDICARE: DR. JENNIFER L 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	071-007651	IL
2	103TB0200X	Cognitive & Behavioral Psychologist	071-007651	IL
3	103TC2200X	Clinical Child & Adolescent Psychologist	071-007651	IL
4	103TF0000X	Family Psychologist	071-007651	IL
5	103TC0700X	Clinical Psychologist	071007651	IL

General Provider Information

NPI Number	:	1164544839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER L 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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	10/13/2014

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