Provider Demographics
NPI:1558825752
Name:LEEDER, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:LEEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:LEEDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11731 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3675
Mailing Address - Country:US
Mailing Address - Phone:626-802-7824
Mailing Address - Fax:
Practice Address - Street 1:11731 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3675
Practice Address - Country:US
Practice Address - Phone:626-802-7824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW103244101YM0800X, 104100000X
171M00000X, 225400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program