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1972690774 NPI number — LESLIE W JACKSON MD

NPI Number: 1972690774
Health Care Provider/Practitioner: LESLIE W JACKSON MD

Information about “1972690774” NPI (LESLIE W JACKSON MD) exists in 1972690774 in HTML format HTML  |  1972690774 in plain Text format TXT  |  1972690774 in PDF (Portable Document Format) PDF  |  1972690774 in an XML format XML  formats.

NPI Number : 1972690774 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1972690774",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "JACKSON",
    "FirstName": "LESLIE",
    "MiddleName": "W",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "MD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "WILGUS",
    "OtherFirstName": "LESLIE",
    "OtherMiddleName": "K",
    "OtherNamePrefix": "DR.",
    "OtherNameSuffix": null,
    "OtherCredential": "MD",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "710 SUNSET DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "LA GRANDE",
    "MailingAddressStateName": "OR",
    "MailingAddressPostalCode": "97850-1200",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "541-663-3000",
    "MailingAddressFaxNumber": "541-975-5115",
    "FirstLinePracticeLocationAddress": "710 SUNSET DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LA GRANDE",
    "PracticeLocationAddressStateName": "OR",
    "PracticeLocationAddressPostalCode": "97850-1200",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "541-663-3000",
    "PracticeLocationAddressFaxNumber": "541-975-5115",
    "EnumerationDate": "10/05/2006",
    "LastUpdateDate": "11/23/2021",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "207RR0500X",
          "TaxonomyName": "Rheumatology Physician",
          "LicenseNumber": "9300627",
          "LicenseNumberStateCode": "NC",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207RR0500X",
          "TaxonomyName": "Rheumatology Physician",
          "LicenseNumber": "M-11620",
          "LicenseNumberStateCode": "ID",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207RR0500X",
          "TaxonomyName": "Rheumatology Physician",
          "LicenseNumber": "MD156467",
          "LicenseNumberStateCode": "OR",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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