Healthcare Provider Details

I. General information

NPI: 1922779172
Provider Name (Legal Business Name): LEANNA MARIE JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 POPLAR ST
MURRAY KY
42071-2432
US

IV. Provider business mailing address

300 S 8TH ST STE 480W
MURRAY KY
42071-2403
US

V. Phone/Fax

Practice location:
  • Phone: 270-762-1100
  • Fax:
Mailing address:
  • Phone: 270-762-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016552
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: