Provider Demographics
NPI:1831497783
Name:LEGGETT, JONATHAN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:LEGGETT
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 1:303 S FIRST ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6211
Mailing Address - Country:US
Mailing Address - Phone:505-397-7197
Mailing Address - Fax:855-340-4551
Practice Address - Street 1:303 S FIRST ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6211
Practice Address - Country:US
Practice Address - Phone:505-397-7197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99045855A103T00000X
NM1279103TC1900X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201050210Medicaid
INM400046833Medicare PIN
IN201050210Medicaid