Provider Demographics
NPI:1518249564
Name:LEACH, JESSICA RENEE (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:LEACH
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-978-2623
Mailing Address - Fax:
Practice Address - Street 1:3480 LANDERS RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117
Practice Address - Country:US
Practice Address - Phone:501-955-5519
Practice Address - Fax:501-955-5529
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4472255A2300X
ARPT33992251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR213203721Medicaid