Provider Demographics
NPI:1831559129
Name:JEFFERSON, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72682-0610
Mailing Address - Country:US
Mailing Address - Phone:870-302-3100
Mailing Address - Fax:870-741-0198
Practice Address - Street 1:213 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:AR
Practice Address - Zip Code:72677
Practice Address - Country:US
Practice Address - Phone:870-404-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P9004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist