Healthcare Provider Details

I. General information

NPI: 1497234728
Provider Name (Legal Business Name): LEONARD JEWELL WAIVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W MAIN ST
CONWAY NH
03818-6142
US

IV. Provider business mailing address

87 WASHINGTON ST
CONWAY NH
03818-6044
US

V. Phone/Fax

Practice location:
  • Phone: 603-447-2111
  • Fax:
Mailing address:
  • Phone: 603-447-3347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number088245-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: