Provider Demographics
NPI:1588989925
Name:GIBSON, JENNIFER (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6888 TALLMADGE RD
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9723
Mailing Address - Country:US
Mailing Address - Phone:330-808-3536
Mailing Address - Fax:
Practice Address - Street 1:339 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720
Practice Address - Country:US
Practice Address - Phone:330-498-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA 3268224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant