Healthcare Provider Details

I. General information

NPI: 1932786043
Provider Name (Legal Business Name): JENNIFER ANN LESLIE EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 GRIFFIN GATE DR
LEXINGTON KY
40511-1378
US

IV. Provider business mailing address

1085 GRIFFIN GATE DR
LEXINGTON KY
40511-1378
US

V. Phone/Fax

Practice location:
  • Phone: 859-312-0212
  • Fax:
Mailing address:
  • Phone: 859-312-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: