Provider Demographics
NPI:1447268990
Name:LEGGOUR, JENNIFER CLAIRE (PSYH)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CLAIRE
Last Name:LEGGOUR
Suffix:
Gender:F
Credentials:PSYH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1062
Mailing Address - Country:US
Mailing Address - Phone:410-641-4598
Mailing Address - Fax:410-543-2233
Practice Address - Street 1:124 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1062
Practice Address - Country:US
Practice Address - Phone:410-641-4598
Practice Address - Fax:410-641-4696
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03814103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019077200Medicaid