Provider Demographics
NPI:1487431920
Name:LEAL, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:LEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 E 46TH ST APT 9
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-6531
Mailing Address - Country:US
Mailing Address - Phone:323-605-3686
Mailing Address - Fax:
Practice Address - Street 1:4001 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2616
Practice Address - Country:US
Practice Address - Phone:562-427-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1253191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program