Provider Demographics
NPI:1093862203
Name:JENNINGS, LEILANI ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:ANN
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 LEAD HILL BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2941
Mailing Address - Country:US
Mailing Address - Phone:916-956-7762
Mailing Address - Fax:916-786-3080
Practice Address - Street 1:1380 LEAD HILL BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2941
Practice Address - Country:US
Practice Address - Phone:916-956-7762
Practice Address - Fax:916-786-3080
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL155790Medicare ID - Type UnspecifiedPROVIDER NUMBER