Provider Demographics
NPI:1669495826
Name:JASCOURT, LEIGH R (PT)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:R
Last Name:JASCOURT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3168 E BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1458
Mailing Address - Country:US
Mailing Address - Phone:602-315-4983
Mailing Address - Fax:
Practice Address - Street 1:2426 W. KIOWA AVENUE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-456-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z127828Medicare PIN