Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019029412 | IL |
NPI | 1003255738 |
---|---|
Provider Name | Dr. Jessica Lynn Gibbs |
First Address | Chicago, IL 60654-4712 |
Second Address | Joliet, IL 60436-1243 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2013 |
Last Update Date | 15/06/2013 |