Healthcare Provider Details

I. General information

NPI: 1841920402
Provider Name (Legal Business Name): VANESSA JESSIE-HUBER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42D MEDICAL GROUP 300 S. TWINING ST., BUILDING 760
MAXWELL AIR FORCE BASE AL
36112-6219
US

IV. Provider business mailing address

42D MEDICAL GROUP 300 S. TWINING ST., BUILDING 760
MAXWELL AIR FORCE BASE AL
36112-6219
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-5430
  • Fax:
Mailing address:
  • Phone: 334-953-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2394
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: