Provider Demographics
NPI:1356728133
Name:LEASURE, JORDYN
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:LEASURE
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 1:1930 HOWARD RD STE 119
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5155
Mailing Address - Country:US
Mailing Address - Phone:559-267-8323
Mailing Address - Fax:
Practice Address - Street 1:1930 HOWARD RD STE 119
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5155
Practice Address - Country:US
Practice Address - Phone:559-267-8323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA1-17-26162103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health