Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | ||
N | 103TC0700X | Clinical Psychologist | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103TA0700X | Adult Development & Aging Psychologist | ||
Y | 103G00000X | Clinical Psychologist | PSY16148 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY16148 | CA |
N | 103TH0100X | Health Service |
NPI | 1386893618 |
---|---|
Provider Name | Dr. Jack Robert Leggett JR. |
First Address | Mission Viejo, CA 92692-5188 |
Second Address | Mission Viejo, CA 92692-5188 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2008 |
Last Update Date | 10/09/2008 |