Provider Demographics
NPI:1558009548
Name:LIEPKE, JASMYNE JAEDYN
Entity Type:Individual
Prefix:
First Name:JASMYNE
Middle Name:JAEDYN
Last Name:LIEPKE
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 1:8074 THURSTON DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9062
Mailing Address - Country:US
Mailing Address - Phone:131-570-6493
Mailing Address - Fax:
Practice Address - Street 1:8074 THURSTON DR
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9062
Practice Address - Country:US
Practice Address - Phone:315-706-4937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor