Healthcare Provider Details

I. General information

NPI: 1295825917
Provider Name (Legal Business Name): JENNIFER S LEACH CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 FARRELL CRES
OWENSBORO KY
42303-1393
US

IV. Provider business mailing address

2845 FARRELL CRES
OWENSBORO KY
42303-1393
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-3297
  • Fax:
Mailing address:
  • Phone: 270-926-3297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA138
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: