Individual
JERAD LEISCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2632 FOOTHILL BLVD, ROCK SPRINGS, WY 82901-4756
(307) 212-3284
Mailing address
310 E BROADWAY AVE, JACKSON, WY 83001-8636
(307) 212-3284
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
RBT-20-149038
WY
Other
Enumeration date
12/23/2020
Last updated
12/23/2020
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