Provider Demographics
NPI:1043197650
Name:BIBBS, KENTON DEQUAN
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:DEQUAN
Last Name:BIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8876 A C SKINNER PKWY UNIT 8216
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0909
Mailing Address - Country:US
Mailing Address - Phone:386-916-1579
Mailing Address - Fax:
Practice Address - Street 1:8876 A C SKINNER PKWY UNIT 8216
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0909
Practice Address - Country:US
Practice Address - Phone:386-916-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL228984171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach