Healthcare Provider Details

I. General information

NPI: 1275017675
Provider Name (Legal Business Name): JACQUELINE LEON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 S JOHNSON FERRY RD
SANDY SPRINGS GA
30319-4301
US

IV. Provider business mailing address

2981 HOLLOW LN
POWDER SPRINGS GA
30127-1864
US

V. Phone/Fax

Practice location:
  • Phone: 678-895-1261
  • Fax:
Mailing address:
  • Phone: 678-895-1261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA002300
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: