Provider Demographics
NPI:1922103340
Name:LIDDELL, JESSICA ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANNE
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNE
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 ACKERSON WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5342
Mailing Address - Country:US
Mailing Address - Phone:530-320-0509
Mailing Address - Fax:
Practice Address - Street 1:2008 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2135
Practice Address - Country:US
Practice Address - Phone:916-973-7329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY22271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program