Provider Demographics
NPI:1306927991
Name:GIBBONS, JEREMY DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DAVID
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-6764
Mailing Address - Country:US
Mailing Address - Phone:435-563-2514
Mailing Address - Fax:435-535-0769
Practice Address - Street 1:1177 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84335-6764
Practice Address - Country:US
Practice Address - Phone:435-563-2514
Practice Address - Fax:435-535-0769
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6095811-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor