Provider Demographics
NPI:1699030858
Name:GIBSON, JASON LEE (LPC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SUN TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8643
Mailing Address - Country:US
Mailing Address - Phone:256-975-4291
Mailing Address - Fax:256-325-1890
Practice Address - Street 1:1040 LONGFIELD CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8055
Practice Address - Country:US
Practice Address - Phone:256-701-5651
Practice Address - Fax:256-429-9411
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional