Provider Demographics
NPI:1912030669
Name:LEBARON, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:LEBARON
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:BIEBER
Mailing Address - State:CA
Mailing Address - Zip Code:96009-0040
Mailing Address - Country:US
Mailing Address - Phone:530-294-5700
Mailing Address - Fax:530-251-2670
Practice Address - Street 1:125 HWY 299 E
Practice Address - Street 2:
Practice Address - City:BIEBER
Practice Address - State:CA
Practice Address - Zip Code:96009
Practice Address - Country:US
Practice Address - Phone:530-294-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801Medicaid