Provider Demographics
NPI:1649538463
Name:LEONARD, JENNIFER BROWN (NP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROWN
Last Name:LEONARD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 E GALA ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8026
Mailing Address - Country:US
Mailing Address - Phone:208-887-3724
Mailing Address - Fax:
Practice Address - Street 1:2235 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8026
Practice Address - Country:US
Practice Address - Phone:208-887-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1577A363L00000X
IDN-36631163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1649538463Medicaid
WA8921726Medicare PIN