Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 42138 | TN |
NPI | 1053926659 |
---|---|
Provider Name | Penny Ann Gibson |
First Address | Jackson, TN 38305-4403 |
Second Address | Jackson, TN 38305-3654 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2020 |
Last Update Date | 10/09/2020 |