Healthcare Provider Details

I. General information

NPI: 1831497783
Provider Name (Legal Business Name): JONATHAN L. LEGGETT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S FIRST ST
GALLUP NM
87301-6211
US

IV. Provider business mailing address

303 S FIRST ST
GALLUP NM
87301-6211
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-7197
  • Fax:
Mailing address:
  • Phone: 505-397-7197
  • Fax: 855-340-4551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number99045855A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1279
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number1279
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: