MEDICARE: DR. R JON LEFFINGWELL

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	20928	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86840A	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1740227578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. R JON LEFFINGWELL

Provider Business Mailing Address
First Line	:	1204 W ABRAM ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-1701
Country	:	US
Telephone Number	:	817-261-0121
Fax Number	:

Provider Business Practice Location Address
First Line	:	1204 W ABRAM ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-1701
Country	:	US
Telephone Number	:	817-261-0121
Fax Number	:

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/08/2007

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