Provider Demographics
NPI:1740026426
Name:LEACH, JUVONTA
Entity type:Individual
Prefix:
First Name:JUVONTA
Middle Name:
Last Name:LEACH
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 1:6125 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3509
Mailing Address - Country:US
Mailing Address - Phone:262-281-0216
Mailing Address - Fax:855-810-4227
Practice Address - Street 1:6125 N 39TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-3509
Practice Address - Country:US
Practice Address - Phone:262-281-0216
Practice Address - Fax:855-810-4227
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0019557311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home