Provider Demographics
NPI:1073276275
Name:GIBBS, JADYN BROOKE (PTA)
Entity type:Individual
Prefix:
First Name:JADYN
Middle Name:BROOKE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 LAZY LN
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-6307
Mailing Address - Country:US
Mailing Address - Phone:580-743-0121
Mailing Address - Fax:
Practice Address - Street 1:1801 CHUKKA HINA
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-7117
Practice Address - Country:US
Practice Address - Phone:580-920-2100
Practice Address - Fax:580-916-9201
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2681225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant