MEDICARE: ADELINE LEON

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	PY10602	FL
2	103G00000X	Clinical Neuropsychologist	PY10602	FL

General Provider Information

NPI Number	:	1477103539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELINE LEON

Provider Business Mailing Address
First Line	:	PO BOX 748519
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8519
Country	:	US
Telephone Number	:	904-376-3800
Fax Number	:	904-376-3998

Provider Business Practice Location Address
First Line	:	836 PRUDENTIAL DR STE 1506
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8342
Country	:	US
Telephone Number	:	904-376-3800
Fax Number	:

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

Provider Enumeration Date	:	09/19/2019
Last Update Date	:	02/09/2026

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Directions to “ ADELINE LEON ” Practice Location

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