MEDICARE: MR. LARRY JACKSON LEGG M.A.

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	103TC0700X	Clinical Psychologist	630	WV
2	103TC1900X	Counseling Psychologist	630	WV
3	103TC2200X	Clinical Child & Adolescent Psychologist	630	WV
4	103TM1800X	Intellectual & Developmental Disabilities Psychologist	630	WV

General Provider Information

NPI Number	:	1366571499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY JACKSON LEGG M.A.

Provider Business Mailing Address
First Line	:	3883 FARMDALE RD
Second Line	:
City	:	MEADOW BRIDGE
State	:	WV
Zip	:	25976-7035
Country	:	US
Telephone Number	:	304-661-2742
Fax Number	:	304-392-6835

Provider Business Practice Location Address
First Line	:	702 PROFESSIONAL PARK DR
Second Line	:	STE 106
City	:	SUMMERSVILLE
State	:	WV
Zip	:	26651-2033
Country	:	US
Telephone Number	:	304-883-2380
Fax Number	:	304-883-2383

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	01/27/2017

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