Provider Demographics
NPI:1386004679
Name:LIVINGSTON, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:
Practice Address - Street 1:631 S ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5011
Practice Address - Country:US
Practice Address - Phone:707-467-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X, 101Y00000X
CA86385101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101Y00000XBehavioral Health & Social Service ProvidersCounselor