Provider Demographics
NPI:1295189769
Name:LEIPHART, JEFFREY MAHLON (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MAHLON
Last Name:LEIPHART
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 1:17852 ARDISIA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1250
Mailing Address - Country:US
Mailing Address - Phone:415-696-0644
Mailing Address - Fax:619-354-2611
Practice Address - Street 1:17852 ARDISIA CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1250
Practice Address - Country:US
Practice Address - Phone:415-696-0644
Practice Address - Fax:619-354-2611
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5757103TC0700X, 103T00000X, 103TH0100X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service