Provider Demographics
NPI:1104619543
Name:GIBSON, JESSICA (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 SPRINGWALK RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-5004
Mailing Address - Country:US
Mailing Address - Phone:901-598-4084
Mailing Address - Fax:
Practice Address - Street 1:3964 GOODMAN RD E STE 105
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8711
Practice Address - Country:US
Practice Address - Phone:662-932-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist