Provider Demographics
NPI:1811564222
Name:LESLIE, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 SW WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2409
Mailing Address - Country:US
Mailing Address - Phone:503-645-3581
Mailing Address - Fax:
Practice Address - Street 1:213 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4825
Practice Address - Country:US
Practice Address - Phone:971-261-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program