Provider Demographics
NPI:1720416043
Name:LEATHERS, JAMAAL LEE
Entity Type:Individual
Prefix:MR
First Name:JAMAAL
Middle Name:LEE
Last Name:LEATHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3548
Mailing Address - Country:US
Mailing Address - Phone:919-381-6583
Mailing Address - Fax:
Practice Address - Street 1:1011 PARK AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3548
Practice Address - Country:US
Practice Address - Phone:919-381-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-032-132311ZA0620X, 320700000X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No376G00000XNursing Service Related ProvidersNursing Home Administrator