Healthcare Provider Details

I. General information

NPI: 1528554334
Provider Name (Legal Business Name): JENNIFER LEACH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 E BASELINE RD STE 106
MESA AZ
85209-5005
US

IV. Provider business mailing address

7242 E MONTE AVE
MESA AZ
85209-4971
US

V. Phone/Fax

Practice location:
  • Phone: 480-823-5777
  • Fax:
Mailing address:
  • Phone: 616-257-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberLPT-30092
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30092
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberLPT-30092
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberLPT-30092
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberLPT-30092
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: