1669617635 NPI number — DR. LEIGHTON JERRY CUNNINGHAM PH.D

Table of content: DR. LEIGHTON JERRY CUNNINGHAM PH.D (NPI 1669617635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669617635 NPI number — DR. LEIGHTON JERRY CUNNINGHAM PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
LEIGHTON
Provider Middle Name:
JERRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669617635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 CLEVELAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-5032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-454-1229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 S KIMBALL AVE
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-3735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-1229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY-424 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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