Healthcare Provider Details

I. General information

NPI: 1164258901
Provider Name (Legal Business Name): JONATHAN ANDERSON LESLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8354 E NORTHFIELD BLVD UNIT 3700
DENVER CO
80238-3135
US

IV. Provider business mailing address

801 S PRUDENCE RD APT 11205
TUCSON AZ
85710-3826
US

V. Phone/Fax

Practice location:
  • Phone: 720-961-3764
  • Fax:
Mailing address:
  • Phone: 520-561-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-332720
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: