Provider Demographics
NPI:1285081869
Name:JEANNIE GIBERSON
Entity type:Organization
Organization Name:JEANNIE GIBERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:JUNIOR
Authorized Official - Last Name:GIBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:352-467-4457
Mailing Address - Street 1:4313 TAHITIAN GARDENS DRIVE K2
Mailing Address - Street 2:K2
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691
Mailing Address - Country:US
Mailing Address - Phone:352-467-4457
Mailing Address - Fax:
Practice Address - Street 1:4313 TAHITIAN GARDENS DRIVE K2
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691
Practice Address - Country:US
Practice Address - Phone:352-467-4457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW13517282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4902Medicaid
FL4902OtherMENTAL HEALTH