Provider Demographics
NPI:1730517574
Name:LEECH, JERRY DALE JR (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DALE
Last Name:LEECH
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:118 BROOKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5604
Mailing Address - Country:US
Mailing Address - Phone:314-972-3107
Mailing Address - Fax:
Practice Address - Street 1:2730 S SAINT PETERS PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-5677
Practice Address - Country:US
Practice Address - Phone:636-244-5239
Practice Address - Fax:888-241-0474
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-14
Last Update Date:2014-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013036906111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor