Provider Demographics
NPI:1619795291
Name:BENNETT, LEIGH ANN JESSICA (R1561070524)
Entity type:Individual
Prefix:
First Name:LEIGH ANN
Middle Name:JESSICA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:R1561070524
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2079 SALICE WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2427
Mailing Address - Country:US
Mailing Address - Phone:925-565-8863
Mailing Address - Fax:
Practice Address - Street 1:2079 SALICE WAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2427
Practice Address - Country:US
Practice Address - Phone:760-672-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool