Provider Demographics
NPI:1225713860
Name:TIBBS, JESSIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:TIBBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 NE 13TH ST (183)
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:405-456-3888
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1431103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical