Provider Demographics
NPI:1407919491
Name:LEEB, JACK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LEEB
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 BRENTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1704
Mailing Address - Country:US
Mailing Address - Phone:301-593-9333
Mailing Address - Fax:
Practice Address - Street 1:914 BRENTWOOD LN
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-1704
Practice Address - Country:US
Practice Address - Phone:301-593-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02732103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical