Healthcare Provider Details

I. General information

NPI: 1740673037
Provider Name (Legal Business Name): JESSICA JOY LIBBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 ALDER AVE
SUMNER WA
98390-1406
US

IV. Provider business mailing address

12425 135TH STREET CT E
PUYALLUP WA
98374-4662
US

V. Phone/Fax

Practice location:
  • Phone: 253-302-9593
  • Fax:
Mailing address:
  • Phone: 253-302-9593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60542500
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF61294021
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: