Provider Demographics
NPI:1336205335
Name:LEISTNER, JAKOB (MA, LCMHC)
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:
Last Name:LEISTNER
Suffix:
Gender:M
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05681-0182
Mailing Address - Country:US
Mailing Address - Phone:802-461-6113
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 182
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:VT
Practice Address - Zip Code:05681-0182
Practice Address - Country:US
Practice Address - Phone:802-461-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT68-495101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007355Medicaid