Provider Demographics
NPI:1235963224
Name:GIDEON, JACOB BRUCE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRUCE
Last Name:GIDEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8802 DEADSTREAM RD
Mailing Address - Street 2:
Mailing Address - City:HONOR
Mailing Address - State:MI
Mailing Address - Zip Code:49640-9769
Mailing Address - Country:US
Mailing Address - Phone:231-871-1337
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 392
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-0392
Practice Address - Country:US
Practice Address - Phone:231-268-0007
Practice Address - Fax:231-525-3170
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician