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General NPI Number Information
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NPI Number | 1760823496
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Entity Type | Individual
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Provider Name | LEIA NICOLE JACKSON D.D.S
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Gender | Female
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Dates
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Enumeration Date | 07/10/2013
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Last Update Date | 07/10/2013
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Provider Practice Location Address
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Address Line | 8707 SPRING CYPRESS RD SUITE A
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City | SPRING
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State | TX
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Zip | 77379-3330
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Country | US
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Telephone | 281-320-1150
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Fax |
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Provider Business Mailing Address
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Address Line | 11245 WEST RD APT #138A
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City | HOUSTON
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State | TX
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Zip | 77065-4828
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Country | US
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Telephone | 605-484-9836
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 29290
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License Number State | TX
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