Provider Demographics
NPI:1396355863
Name:LEADER, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEADER
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 1:1769 GLENDON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5705
Mailing Address - Country:US
Mailing Address - Phone:310-689-6648
Mailing Address - Fax:
Practice Address - Street 1:11600 WASHINGTON PL STE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5068
Practice Address - Country:US
Practice Address - Phone:310-689-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8173101YM0800X
CA120691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health