Healthcare Provider Details

I. General information

NPI: 1154352086
Provider Name (Legal Business Name): EDWARD C LEICHNER JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 OLD HICKORY BLVD
JACKSON TN
38305-2562
US

IV. Provider business mailing address

180 OLD HICKORY BLVD
JACKSON TN
38305-2562
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-2750
  • Fax: 731-664-6817
Mailing address:
  • Phone: 731-661-2750
  • Fax: 731-664-6817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO1128
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: