Provider Demographics
NPI:1053921585
Name:GIBSON, JESSICA ANNA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5635
Mailing Address - Country:US
Mailing Address - Phone:413-219-6702
Mailing Address - Fax:
Practice Address - Street 1:3 PARK DR
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3511
Practice Address - Country:US
Practice Address - Phone:978-392-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist