Provider Demographics
NPI:1710303102
Name:CASPER, JENNIFER (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CASPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NIBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:308 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1946
Mailing Address - Country:US
Mailing Address - Phone:925-984-7036
Mailing Address - Fax:
Practice Address - Street 1:1749 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-2139
Practice Address - Country:US
Practice Address - Phone:510-841-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X
CA34075103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker