Provider Demographics
NPI:1255321444
Name:LECKIE, JOHN FANNIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FANNIN
Last Name:LECKIE
Suffix:
Gender:M
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:PO BOX 4413
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-4413
Mailing Address - Country:US
Mailing Address - Phone:530-220-4757
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNIA DRIVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95696-1800
Practice Address - Country:US
Practice Address - Phone:707-448-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30801103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling