Healthcare Provider Details

I. General information

NPI: 1649725995
Provider Name (Legal Business Name): JACLYN LEITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2479 5TH ST.
FT. MEADE MD
20755
US

IV. Provider business mailing address

1321 EUTAW PL APT B
BALTIMORE MD
21217-3636
US

V. Phone/Fax

Practice location:
  • Phone: 410-305-5325
  • Fax:
Mailing address:
  • Phone: 410-305-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number05706
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: