Provider Demographics
NPI:1124446364
Name:GIBSON, JESSICA N (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:N
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:N
Other - Last Name:STURDIVANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:124 STURBRIDGE DR
Mailing Address - Street 2:GEORGETOWN
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-2536
Mailing Address - Country:US
Mailing Address - Phone:606-424-7137
Mailing Address - Fax:
Practice Address - Street 1:105 WINDSOR PATH STE 1
Practice Address - Street 2:GEORGETOWN
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9617
Practice Address - Country:US
Practice Address - Phone:502-570-2337
Practice Address - Fax:502-570-2338
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000869196OtherANTHEM
KY7100300660Medicaid
KYK136160Medicare PIN