Provider Demographics
NPI:1053802207
Name:GIBSON, JORDAN N (DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:N
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:872 PRICES FORK RD
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-3229
Practice Address - Country:US
Practice Address - Phone:540-739-2161
Practice Address - Fax:540-739-7477
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist