Provider Demographics
NPI:1639334410
Name:LIESKE, JESSICA MIRANDA (TLMLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MIRANDA
Last Name:LIESKE
Suffix:
Gender:F
Credentials:TLMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7840 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-2152
Mailing Address - Country:US
Mailing Address - Phone:913-328-4600
Mailing Address - Fax:
Practice Address - Street 1:7840 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2152
Practice Address - Country:US
Practice Address - Phone:913-328-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080COtherSED WAIVER
KS100098080AMedicaid
KS3620000Medicare PIN