Provider Demographics
NPI:1740673037
Name:LIBBY, JESSICA JOY
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOY
Last Name:LIBBY
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 1:12425 135TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4662
Mailing Address - Country:US
Mailing Address - Phone:253-302-9593
Mailing Address - Fax:
Practice Address - Street 1:918 ALDER AVE
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1406
Practice Address - Country:US
Practice Address - Phone:253-302-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61294021106H00000X
101Y00000X
WACG60542500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health