Provider Demographics
NPI:1639842990
Name:LEICHT, JENNIFER REBECCA (RDHAP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:LEICHT
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5349 LARCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-3041
Mailing Address - Country:US
Mailing Address - Phone:408-455-2239
Mailing Address - Fax:
Practice Address - Street 1:5349 LARCHWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3041
Practice Address - Country:US
Practice Address - Phone:408-455-2239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA853124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist