Provider Demographics
NPI:1710748439
Name:GIBSON, JENNA (CNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DEBARTOLO PL STE 200
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6095
Mailing Address - Country:US
Mailing Address - Phone:330-729-8146
Mailing Address - Fax:330-965-5229
Practice Address - Street 1:250 DEBARTOLO PL STE B
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-7004
Practice Address - Country:US
Practice Address - Phone:234-375-0659
Practice Address - Fax:330-758-3282
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0035643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0040434Medicaid