Provider Demographics
NPI:1780388942
Name:LEAK, JAISYN
Entity type:Individual
Prefix:
First Name:JAISYN
Middle Name:
Last Name:LEAK
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 1:3670 N LIVE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-3428
Mailing Address - Country:US
Mailing Address - Phone:951-283-9289
Mailing Address - Fax:
Practice Address - Street 1:3670 N LIVE OAK AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-3428
Practice Address - Country:US
Practice Address - Phone:951-283-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty