Provider Demographics
NPI:1639592694
Name:LEAHY, JESSICA LYNN (IDMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LEAHY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 POINT SUNSET
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5550
Mailing Address - Country:US
Mailing Address - Phone:717-676-8120
Mailing Address - Fax:
Practice Address - Street 1:707 POINT SUNSET
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5550
Practice Address - Country:US
Practice Address - Phone:717-676-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians