Provider Demographics
NPI:1780913509
Name:LEACH, JENNIFER A (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LEACH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE
Mailing Address - Street 2:STE 400
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-6644
Mailing Address - Fax:309-692-3320
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:STE 400
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-692-6644
Practice Address - Fax:309-692-3320
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL160002608225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant