Provider Demographics
NPI:1245904184
Name:LEACH, JESSICA N
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:LEACH
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 1:797 COUNTY ROAD 16
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-6686
Mailing Address - Country:US
Mailing Address - Phone:870-291-2523
Mailing Address - Fax:
Practice Address - Street 1:1310 BRADLEY DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2730
Practice Address - Country:US
Practice Address - Phone:870-291-2523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4691225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant