Provider Demographics
NPI:1437480480
Name:LECKIE, JENNIFER DAWN (PA-C, LAC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DAWN
Last Name:LECKIE
Suffix:
Gender:F
Credentials:PA-C, LAC
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:905 VERDAE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4098
Practice Address - Country:US
Practice Address - Phone:864-990-1910
Practice Address - Fax:864-990-1911
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3433363A00000X
SC269171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist