MEDICARE: DR. LESLIE JENNICE HARRISON LMFT

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	106H00000X	Marriage & Family Therapist	MFT000969	GA
2	106H00000X	Marriage & Family Therapist	MT2943	FL

General Provider Information

NPI Number	:	1801022819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE JENNICE HARRISON LMFT

Provider Business Mailing Address
First Line	:	120 EVEREST LN STE 3
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-4063
Country	:	US
Telephone Number	:	850-771-8882
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 EVEREST LN STE 3
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-4063
Country	:	US
Telephone Number	:	850-771-8882
Fax Number	:

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

Provider Enumeration Date	:	06/04/2009
Last Update Date	:	08/16/2024

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