Provider Demographics
NPI:1497897615
Name:LIBERTY, JAIMIE LEE (MFT)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:LEE
Last Name:LIBERTY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9177 CANDLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1232
Mailing Address - Country:US
Mailing Address - Phone:909-484-7352
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:626-967-6027
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40291106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist