Provider Demographics
NPI:1114587953
Name:LEADERMAN, JARED KYLE (LPCC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:KYLE
Last Name:LEADERMAN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 FABIAN WAY
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-4605
Mailing Address - Country:US
Mailing Address - Phone:424-248-5586
Mailing Address - Fax:
Practice Address - Street 1:421 N SHORELINE BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043
Practice Address - Country:US
Practice Address - Phone:424-248-5586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty