Provider Demographics
NPI:1023624269
Name:GIBAS, JESSILYN
Entity type:Individual
Prefix:
First Name:JESSILYN
Middle Name:
Last Name:GIBAS
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 N NATIONAL RD STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5501
Practice Address - Country:US
Practice Address - Phone:812-799-1257
Practice Address - Fax:812-799-1258
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025477225100000X
VA2305216863225100000X
IN05015741A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist