Healthcare Provider Details

I. General information

NPI: 1609022029
Provider Name (Legal Business Name): JESSICA WILEY LESLIE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA RENEE WILEY LCSW

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E KALISTE SALOOM RD STE 400N
LAFAYETTE LA
70508-2540
US

IV. Provider business mailing address

126 DARCY DR
ARCHER LODGE NC
27527-7309
US

V. Phone/Fax

Practice location:
  • Phone: 337-504-3802
  • Fax: 800-398-9547
Mailing address:
  • Phone: 337-349-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103893
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8570
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW15676
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC17354
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20261
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008048
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: