Healthcare Provider Details

I. General information

NPI: 1487431920
Provider Name (Legal Business Name): JORGE LEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 LONG BEACH BLVD
LONG BEACH CA
90807-2616
US

IV. Provider business mailing address

761 E 46TH ST APT 9
LONG BEACH CA
90807-6531
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-7671
  • Fax:
Mailing address:
  • Phone: 323-605-3686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125319
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: