Provider Demographics
NPI:1144299900
Name:GIBSON, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 N ANCHOR ST STE 300A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7679
Mailing Address - Country:US
Mailing Address - Phone:503-283-0013
Mailing Address - Fax:503-283-0785
Practice Address - Street 1:3449 N ANCHOR ST STE 300A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7679
Practice Address - Country:US
Practice Address - Phone:503-283-0013
Practice Address - Fax:503-283-0785
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37913208VP0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1144299900Medicaid
IA1144299900OtherMN MEDICAID
IA1144299900OtherWELLMARK
IA1144299900Medicaid