Provider Demographics
NPI:1780214106
Name:LELEK, JEREMY ADAM (PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ADAM
Last Name:LELEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126558
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-6558
Mailing Address - Country:US
Mailing Address - Phone:817-571-4110
Mailing Address - Fax:
Practice Address - Street 1:2501 PARKVIEW DR STE 220
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5824
Practice Address - Country:US
Practice Address - Phone:817-571-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18370101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional