Provider Demographics
NPI:1831681360
Name:LESLIE, JACOB DENNIS (ATC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DENNIS
Last Name:LESLIE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FOXBORO DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-6421
Mailing Address - Country:US
Mailing Address - Phone:731-518-5376
Mailing Address - Fax:
Practice Address - Street 1:915 E MARKET AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72149-5615
Practice Address - Country:US
Practice Address - Phone:731-518-5376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR20000315742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer