Provider Demographics
NPI:1477980431
Name:LEONG, JENNIFER J (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:LEONG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1279
Mailing Address - Street 2:
Mailing Address - City:IDYLLWILD
Mailing Address - State:CA
Mailing Address - Zip Code:92549-1279
Mailing Address - Country:US
Mailing Address - Phone:424-703-4007
Mailing Address - Fax:
Practice Address - Street 1:55075 DARYLL RD
Practice Address - Street 2:
Practice Address - City:IDYLLWILD
Practice Address - State:CA
Practice Address - Zip Code:92549
Practice Address - Country:US
Practice Address - Phone:424-703-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT101032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist