Healthcare Provider Details

I. General information

NPI: 1629385422
Provider Name (Legal Business Name): JACQUELYN COURTNEY LANSDALE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE LANSDALE MCLEISH M.A.

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6951 PISTOL RANGE RD STE 101
TAMPA FL
33635-9613
US

IV. Provider business mailing address

175 MIDDLE ST UNIT 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 813-814-2007
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-13230
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: