=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265205918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKSON LEAL PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2023
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 S MAIN ST
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-443-3721
-----------------------------------------------------
Fax | 732-733-2641
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 S MAIN ST
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-443-3721
-----------------------------------------------------
Fax | 732-733-2641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA02258900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------