Provider Demographics
NPI:1114678760
Name:LEAVELL, JESSICA ROSE (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:LEAVELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11541 NORGATE CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-9117
Mailing Address - Country:US
Mailing Address - Phone:951-520-7291
Mailing Address - Fax:
Practice Address - Street 1:2201 KILSON DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-2954
Practice Address - Country:US
Practice Address - Phone:949-734-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1389630520101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)