Provider Demographics
NPI:1821531419
Name:DONNELSON, LEAH JAN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:JAN
Last Name:DONNELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 S JOHN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0632
Mailing Address - Country:US
Mailing Address - Phone:417-425-0198
Mailing Address - Fax:
Practice Address - Street 1:1359 S JOHN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0632
Practice Address - Country:US
Practice Address - Phone:417-425-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016041778104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker