=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902161243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOWARD LESLIE JACKSON PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2012
-----------------------------------------------------
Last Update Date | 07/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7801 AIRPORT PULLING RD N
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34109-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-566-2817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 KENNEDY PL
-----------------------------------------------------
City | TUCKAHOE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10707-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-506-0262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | PT 18310
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------