Provider Demographics
NPI:1649725995
Name:LEITH, JACLYN (PHD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:LEITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 EUTAW PL
Mailing Address - Street 2:APT B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3636
Mailing Address - Country:US
Mailing Address - Phone:410-305-5325
Mailing Address - Fax:
Practice Address - Street 1:2479 5TH ST.
Practice Address - Street 2:
Practice Address - City:FT. MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755
Practice Address - Country:US
Practice Address - Phone:410-305-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05706103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical