Provider Demographics
NPI:1104649599
Name:LEIGHT, JACKQUELINE ANN
Entity type:Individual
Prefix:
First Name:JACKQUELINE
Middle Name:ANN
Last Name:LEIGHT
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 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-523-6773
Mailing Address - Fax:
Practice Address - Street 1:10801 BLACK BEAR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-523-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician