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General NPI Number Information
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NPI Number | 1386821502
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Entity Type | Organization
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Legal Business Name | LESLIE JACKSON, MD
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Dates
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Enumeration Date | 01/30/2008
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 115 E PLEASANT ST
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City | TAYLORVILLE
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State | IL
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Zip | 62568-1560
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Country | US
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Telephone | 217-824-3757
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Fax | 217-824-9604
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Provider Business Mailing Address
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Address Line | 115 E PLEASANT ST P O BOX 318
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City | TAYLORVILLE
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State | IL
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Zip | 62568-1560
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Country | US
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Telephone | 217-824-3757
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Fax | 217-824-9604
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LESLIE JACKSON
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Credential | MD
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Telephone | 217-824-3757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036072876
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License Number State | IL
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