Provider Demographics
NPI:1003606278
Name:LEISEN, JENNIFER JEAN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN
Last Name:LEISEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10996 HYLAND TER
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-4018
Mailing Address - Country:US
Mailing Address - Phone:763-200-2667
Mailing Address - Fax:
Practice Address - Street 1:1517 HIGHWAY 13 E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2917
Practice Address - Country:US
Practice Address - Phone:612-756-9107
Practice Address - Fax:612-234-3398
Is Sole Proprietor?:No
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician