Provider Demographics
NPI:1174066575
Name:THIBEAULT, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THIBEAULT
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 1:4179 PIEDMONT AVE
Mailing Address - Street 2:#201
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5186
Mailing Address - Country:US
Mailing Address - Phone:510-333-4579
Mailing Address - Fax:
Practice Address - Street 1:4179 PIEDMONT AVE
Practice Address - Street 2:#201
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5186
Practice Address - Country:US
Practice Address - Phone:510-333-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16670225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT16670OtherOCCUPATIONAL THERAPIST