Provider Demographics
NPI:1992080980
Name:GIBSON, JILLIAN RAE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E. CENTENNIAL PARKWAY
Mailing Address - Street 2:APT. 2120
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084
Mailing Address - Country:US
Mailing Address - Phone:614-769-3307
Mailing Address - Fax:
Practice Address - Street 1:245 E. CENTENNIAL PARKWAY
Practice Address - Street 2:APT. 2120
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084
Practice Address - Country:US
Practice Address - Phone:614-769-3307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker