Provider Demographics
NPI:1184264244
Name:LEACH, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:LEACH
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 1:4459 N ELSINORE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6259
Mailing Address - Country:US
Mailing Address - Phone:208-954-4558
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-706-5000
Practice Address - Fax:208-706-5000
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist