Provider Demographics
NPI:1669021242
Name:JACKSON, LEONTAY
Entity Type:Individual
Prefix:
First Name:LEONTAY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 12TH ST SE APT 506
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2942
Mailing Address - Country:US
Mailing Address - Phone:202-375-0164
Mailing Address - Fax:
Practice Address - Street 1:324 37TH ST SE APT 304
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3142
Practice Address - Country:US
Practice Address - Phone:202-808-2437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor