Provider Demographics
NPI:1962067553
Name:LEDDY, JESSICA (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEDDY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1415
Mailing Address - Country:US
Mailing Address - Phone:862-812-1000
Mailing Address - Fax:
Practice Address - Street 1:5 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:NJ
Practice Address - Zip Code:07068-1415
Practice Address - Country:US
Practice Address - Phone:862-812-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist