Provider Demographics
NPI:1720121627
Name:PICKARD, LEIGH B (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:B
Last Name:PICKARD
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-621-5081
Mailing Address - Fax:
Practice Address - Street 1:1850 CHADWICK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3404
Practice Address - Country:US
Practice Address - Phone:601-373-1793
Practice Address - Fax:601-376-1466
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1161133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1720121627Medicaid