Provider Demographics
NPI:1033267802
Name:LEIDERMAN, JACK FREDRIC (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:FREDRIC
Last Name:LEIDERMAN
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10475
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20849-0475
Mailing Address - Country:US
Mailing Address - Phone:240-731-5353
Mailing Address - Fax:
Practice Address - Street 1:12 S ADAMS ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4238
Practice Address - Country:US
Practice Address - Phone:240-731-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD079331041C0700X
VA09040043771041C0700X
DCLC3023771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LE445792Medicare ID - Type Unspecified