Provider Demographics
NPI:1417498874
Name:LEIGH, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LEIGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 20TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4607
Mailing Address - Country:US
Mailing Address - Phone:618-514-8494
Mailing Address - Fax:
Practice Address - Street 1:1412 20TH ST
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4607
Practice Address - Country:US
Practice Address - Phone:618-514-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.019546225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist