Provider Demographics
NPI:1730726951
Name:LEAL, JEANETTE ELLEN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ELLEN
Last Name:LEAL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 WALNUT ST APT A
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26351-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH ST
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1200
Practice Address - Country:US
Practice Address - Phone:304-462-7361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0889312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer