Healthcare Provider Details

I. General information

NPI: 1245804004
Provider Name (Legal Business Name): JORGE LEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S BRAND BLVD UNIT 307
SAN FERNANDO CA
91340-4040
US

IV. Provider business mailing address

601 S BRAND BLVD UNIT 307
SAN FERNANDO CA
91340-4040
US

V. Phone/Fax

Practice location:
  • Phone: 661-741-2561
  • Fax: 800-852-3387
Mailing address:
  • Phone: 661-741-2561
  • Fax: 800-852-3387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: