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General NPI Number Information
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NPI Number | 1649320904
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Entity Type | Individual
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Provider Name | LESLIE K JACKSON MD
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Gender | Female
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 04/13/2010
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Provider Practice Location Address
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Address Line | 404 E MAIN CROSS ST
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City | TAYLORVILLE
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State | IL
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Zip | 62568-2656
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Country | US
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Telephone | 217-824-3758
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Fax | 217-824-3758
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Provider Business Mailing Address
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Address Line | 404 E MAIN CROSS ST P O BOX 318
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City | TAYLORVILLE
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State | IL
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Zip | 62568-2656
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Country | US
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Telephone | 217-824-3758
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Fax | 217-824-3758
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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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