Provider Demographics
NPI:1225297609
Name:THIVIERGE, JESSICA LEIGH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEIGH
Last Name:THIVIERGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:MACAULAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1501 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3291
Mailing Address - Country:US
Mailing Address - Phone:619-306-3225
Mailing Address - Fax:
Practice Address - Street 1:1501 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3291
Practice Address - Country:US
Practice Address - Phone:619-306-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSB94021710103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health