Provider Demographics
NPI:1164258901
Name:LESLIE, JONATHAN ANDERSON
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDERSON
Last Name:LESLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S PRUDENCE RD APT 11205
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3826
Mailing Address - Country:US
Mailing Address - Phone:520-561-4941
Mailing Address - Fax:
Practice Address - Street 1:8354 E NORTHFIELD BLVD UNIT 3700
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3135
Practice Address - Country:US
Practice Address - Phone:720-961-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-24-332720106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician