Provider Demographics
NPI:1164806964
Name:LEEBOWO, JESSICA (MS)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:LEEBOWO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 37TH AVE, 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403
Mailing Address - Country:US
Mailing Address - Phone:650-242-0179
Mailing Address - Fax:
Practice Address - Street 1:915 54TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-3142
Practice Address - Country:US
Practice Address - Phone:510-879-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210114365103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool