Provider Demographics
NPI:1497953442
Name:LEATH, JENNIFER MARIE (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:LEATH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 QUAIL ST STE 136
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2788
Mailing Address - Country:US
Mailing Address - Phone:949-385-2775
Mailing Address - Fax:949-336-3763
Practice Address - Street 1:1400 QUAIL ST STE 136
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2788
Practice Address - Country:US
Practice Address - Phone:949-385-2775
Practice Address - Fax:949-336-3763
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26109103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical