Healthcare Provider Details

I. General information

NPI: 1497663728
Provider Name (Legal Business Name): JENNIE LIEBERMANN RN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 N CAPITOL AVE
SAN JOSE CA
95133-1316
US

IV. Provider business mailing address

612 S EL CAMINO REAL APT 2
SAN MATEO CA
94402-1712
US

V. Phone/Fax

Practice location:
  • Phone: 408-917-8818
  • Fax: 408-347-5526
Mailing address:
  • Phone: 408-917-8183
  • Fax: 408-347-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number95408971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: