MEDICARE: JADE CHARNAE LEAK MSW, LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1013526771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE CHARNAE LEAK MSW, LCSWA

Provider Business Mailing Address
First Line	:	11100 NORTHLAKE LANDING DR APT 3304
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-0230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5820 E W T HARRIS BLVD STE 205
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-4032
Country	:	US
Telephone Number	:	704-469-1243
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	08/19/2022

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