Provider Demographics
NPI:1851261945
Name:GIBSON, JAX (PHARMD)
Entity type:Individual
Prefix:
First Name:JAX
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 REESE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-8214
Mailing Address - Country:US
Mailing Address - Phone:904-940-5556
Mailing Address - Fax:904-940-8965
Practice Address - Street 1:5440 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-1349
Practice Address - Country:US
Practice Address - Phone:904-940-5556
Practice Address - Fax:904-940-8965
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS69543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist