MEDICARE: MS. JAN MARIE 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	124Q00000X	Dental Hygienist	6445	WA

General Provider Information

NPI Number	:	1417911496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAN MARIE GIBSON

Provider Business Mailing Address
First Line	:	215 SHERIDAN RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79906-3803
Country	:	US
Telephone Number	:	253-283-9106
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 128 CHAFFEE RD, US ARMY DENTAL ACTIVITY
Second Line	:	ATTN: DENTAC HEADQUEARTERS
City	:	FORT BLISS
State	:	TX
Zip	:	79916
Country	:	US
Telephone Number	:	915-742-6001
Fax Number	:

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	06/16/2016

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