Provider Demographics
NPI:1790823805
Name:LEITMAN, JACOB (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LEITMAN
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 PINE BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5284
Mailing Address - Country:US
Mailing Address - Phone:732-410-7820
Mailing Address - Fax:732-410-7821
Practice Address - Street 1:26 PINE BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5284
Practice Address - Country:US
Practice Address - Phone:732-410-7820
Practice Address - Fax:732-410-7821
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00507600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist