Provider Demographics
NPI:1871974055
Name:VAN LEIJSEN, GEORGIA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:VAN LEIJSEN
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 1:4654 HICKORY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5846
Mailing Address - Country:US
Mailing Address - Phone:601-622-6277
Mailing Address - Fax:
Practice Address - Street 1:599 HIGHLAND COLONY PKWY STE 110
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6075
Practice Address - Country:US
Practice Address - Phone:601-202-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2024-06-03
Deactivation Date:2024-05-20
Deactivation Code:
Reactivation Date:2024-06-03
Provider Licenses
StateLicense IDTaxonomies
NMAT7152255A2300X
390200000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program