Basic Information
| Provider Information | |||||||||
| NPI: | 1053845131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIDEON | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316607971 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 CHERE CAROL RD | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383433638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318245551 | ||||||||
| FaxNumber: | 7318245568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2017 | ||||||||
| LastUpdateDate: | 04/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 6266 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.