Provider Demographics
NPI:1063285609
Name:GIBSON, JAQUAN LAMONT
Entity type:Individual
Prefix:MR
First Name:JAQUAN
Middle Name:LAMONT
Last Name:GIBSON
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 1:2616 DENMARK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4632
Mailing Address - Country:US
Mailing Address - Phone:614-554-9172
Mailing Address - Fax:
Practice Address - Street 1:2616 DENMARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4632
Practice Address - Country:US
Practice Address - Phone:614-554-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker