Provider Demographics
NPI:1750801437
Name:EDDY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EDDY
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 1:924 EMERALD BAY RD STE A2
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6434
Mailing Address - Country:US
Mailing Address - Phone:530-544-2111
Mailing Address - Fax:
Practice Address - Street 1:924 EMERALD BAY RD STE A2
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6434
Practice Address - Country:US
Practice Address - Phone:530-544-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist