Provider Demographics
NPI:1497639058
Name:GIBSON, JENNIFER KIMBERLY
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KIMBERLY
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 1:17150 GOLDEN STAR DR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-7663
Mailing Address - Country:US
Mailing Address - Phone:440-915-7551
Mailing Address - Fax:
Practice Address - Street 1:17150 GOLDEN STAR DR
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-7663
Practice Address - Country:US
Practice Address - Phone:440-915-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0036282363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty