Provider Demographics
NPI:1912064007
Name:LEISEGANG, JENNIFER ALICE (RN, MSN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALICE
Last Name:LEISEGANG
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ALICE
Other - Last Name:SALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4745 N GOLF COURSE DR
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-6818
Mailing Address - Country:US
Mailing Address - Phone:360-820-4349
Mailing Address - Fax:
Practice Address - Street 1:4745 N GOLF COURSE DR
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-6818
Practice Address - Country:US
Practice Address - Phone:360-820-4349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00148274163W00000X, 163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development