Provider Demographics
NPI:1306131503
Name:LY, JENNIFER (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 18TH STREET, BOX 3136
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-3134
Mailing Address - Country:US
Mailing Address - Phone:415-476-3658
Mailing Address - Fax:415-502-6361
Practice Address - Street 1:675 18TH STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-3134
Practice Address - Country:US
Practice Address - Phone:415-476-3658
Practice Address - Fax:415-502-6361
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27393103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent