Basic Information
| Provider Information | |||||||||
| NPI: | 1497897615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIBERTY | ||||||||
| FirstName: | JAIMIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9177 CANDLEWOOD ST | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917301232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094847352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1126 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269671667 | ||||||||
| FaxNumber: | 6269676027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC40291 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.