Provider Demographics
NPI:1114430667
Name:LUCASON LECKNER, JESSICA KELLY (LCSW, RPT-S, PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KELLY
Last Name:LUCASON LECKNER
Suffix:
Gender:F
Credentials:LCSW, RPT-S, PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KELLY
Other - Last Name:LUCASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW, RPT
Mailing Address - Street 1:4436 PARVIEW DR N
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3419
Mailing Address - Country:US
Mailing Address - Phone:310-908-9887
Mailing Address - Fax:
Practice Address - Street 1:4436 PARVIEW DR N
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3419
Practice Address - Country:US
Practice Address - Phone:310-908-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0093311041C0700X
CA213471041C0700X
NCC0028771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002176Medicaid