Healthcare Provider Details

I. General information

NPI: 1114587953
Provider Name (Legal Business Name): JARED KYLE LEADERMAN LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N SHORELINE BLVD SUITE 4
MOUNTAIN VIEW CA
94043
US

IV. Provider business mailing address

3900 FABIAN WAY
PALO ALTO CA
94303-4605
US

V. Phone/Fax

Practice location:
  • Phone: 424-248-5586
  • Fax:
Mailing address:
  • Phone: 424-248-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: