Provider Demographics
NPI:1174067227
Name:GIBSON, JAMIE (APN, NP-C)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3598 HOUGHTBY RD
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:IL
Mailing Address - Zip Code:61353-9582
Mailing Address - Country:US
Mailing Address - Phone:815-761-4303
Mailing Address - Fax:
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:815-756-4892
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015241363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner