Provider Demographics
NPI:1700982576
Name:SHADDOCK, JESSICA LONDON L S HUFFINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LONDON L S HUFFINE
Last Name:SHADDOCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 MATHEWS ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-2216
Mailing Address - Country:US
Mailing Address - Phone:510-717-6761
Mailing Address - Fax:
Practice Address - Street 1:842 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-2315
Practice Address - Country:US
Practice Address - Phone:510-717-6761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical