Provider Demographics
NPI:1558982082
Name:BYE, KIMBERLY JACKSON
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JACKSON
Last Name:BYE
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 1:137 N LARCHMONT BLVD # 602
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3704
Mailing Address - Country:US
Mailing Address - Phone:323-580-4686
Mailing Address - Fax:
Practice Address - Street 1:663 LILLIAN WAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1107
Practice Address - Country:US
Practice Address - Phone:323-580-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist