Provider Demographics
NPI:1386483139
Name:JACKSON, LIBBY LOUISE
Entity type:Individual
Prefix:
First Name:LIBBY
Middle Name:LOUISE
Last Name:JACKSON
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 1:2407 DANA ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2207
Mailing Address - Country:US
Mailing Address - Phone:510-517-4756
Mailing Address - Fax:
Practice Address - Street 1:425 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-1936
Practice Address - Country:US
Practice Address - Phone:669-245-3428
Practice Address - Fax:408-800-4095
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137358106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty