Basic Information
| Provider Information | |||||||||
| NPI: | 1952398307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30180 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352511000 | ||||||||
| FaxNumber: | 4356885514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 E MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847902123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352511000 | ||||||||
| FaxNumber: | 4356885514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 3723144901 | UT | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | D3424 | 05 | UT | MEDICAID | 844515 | 05 | AZ | MEDICAID |