Provider Demographics
NPI:1679139497
Name:JENNINGS, LESLIE (OTR)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 KESSLER PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2725
Mailing Address - Country:US
Mailing Address - Phone:903-285-3572
Mailing Address - Fax:
Practice Address - Street 1:22 SOUTHPARK SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3307
Practice Address - Country:US
Practice Address - Phone:870-845-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118980225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist