Basic Information
| Provider Information | |||||||||
| NPI: | 1801820709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | JENIFER | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD CCC A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 E BELLA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636863189 | ||||||||
| FaxNumber: | 8636821348 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 E BELLA VISTA ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636863189 | ||||||||
| FaxNumber: | 8636821348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY1261 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 06582 | 01 | FL | HEAR USA | OTHER | 11982001 | 01 | CITRUS HEALTHCARE | OTHER | 52937 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 190026 | 01 | FL | AMERIGROUP | OTHER |