MEDICARE: JACQUANNA JANICE LEYSATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1104578061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUANNA JANICE LEYSATH

Provider Business Mailing Address
First Line	:	1607 F AVE
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-6174
Country	:	US
Telephone Number	:	803-552-1102
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 F AVE
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-6174
Country	:	US
Telephone Number	:	803-552-1102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	01/21/2022

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