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General NPI Number Information
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NPI Number | 1114430667
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Entity Type | Individual
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Provider Name | JESSICA KELLY LUCASON LECKNER LCSW, RPT-S, PH.D
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Gender | Female
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Dates
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Enumeration Date | 11/07/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 4436 PARVIEW DR N
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City | CHARLOTTE
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State | NC
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Zip | 28226-3419
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Country | US
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Telephone | 310-908-9887
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Fax |
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Provider Business Mailing Address
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Address Line | 4436 PARVIEW DR N
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City | CHARLOTTE
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State | NC
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Zip | 28226-3419
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Country | US
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Telephone | 310-908-9887
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 009331
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 21347
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C002877
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License Number State | NC
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