Healthcare Provider Details

I. General information

NPI: 1790550739
Provider Name (Legal Business Name): JESSICA LEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7271 N. MAIN STREET, SUITE 3
DAYTON OH
45415
US

IV. Provider business mailing address

2504 HOME AVE
DAYTON OH
45417
US

V. Phone/Fax

Practice location:
  • Phone: 937-203-4928
  • Fax:
Mailing address:
  • Phone: 513-567-5933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: