Provider Demographics
NPI:1447301981
Name:LESLIE, JODI (PHD)
Entity type:Individual
Prefix:DR
First Name:JODI
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:J
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1275 BIG FLAT RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9217
Mailing Address - Country:US
Mailing Address - Phone:406-728-1413
Mailing Address - Fax:
Practice Address - Street 1:1275 BIG FLAT RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-9217
Practice Address - Country:US
Practice Address - Phone:406-728-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT960101YP2500X
UT115184-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT944653OtherLCPC
MT0000253164Medicaid