Provider Demographics
NPI:1912038480
Name:LESLIE, JERRY DEAN (LCP,LMFT,LCDC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEAN
Last Name:LESLIE
Suffix:
Gender:M
Credentials:LCP,LMFT,LCDC
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 1391
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76804-1391
Mailing Address - Country:US
Mailing Address - Phone:325-649-4357
Mailing Address - Fax:
Practice Address - Street 1:205 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-2919
Practice Address - Country:US
Practice Address - Phone:325-649-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8837101Y00000X, 101YP2500X
TX6165101YA0400X
TX673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2439676OtherCIGNA