Provider Demographics
NPI:1306835921
Name:LEONARDS, JEFFREY T (PHD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:T
Last Name:LEONARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:T
Other - Last Name:LEONARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:180 MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-1921
Mailing Address - Country:US
Mailing Address - Phone:207-778-4315
Mailing Address - Fax:
Practice Address - Street 1:180 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-1921
Practice Address - Country:US
Practice Address - Phone:207-778-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME123060099Medicaid