Provider Demographics
NPI:1417728189
Name:LIBBEY, JESSICA CATHERINE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CATHERINE
Last Name:LIBBEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5299 COLLEGE AVE STE P
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2816
Mailing Address - Country:US
Mailing Address - Phone:510-878-5496
Mailing Address - Fax:
Practice Address - Street 1:5299 COLLEGE AVE STE 3P
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2808
Practice Address - Country:US
Practice Address - Phone:510-878-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12048101YP2500X
CA134287106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional