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General NPI Number Information
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NPI Number | 1972690774
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Entity Type | Individual
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Provider Name | LESLIE W JACKSON MD
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Gender | Female
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 710 SUNSET DR
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City | LA GRANDE
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State | OR
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Zip | 97850-1200
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Country | US
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Telephone | 541-663-3000
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Fax | 541-975-5115
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Provider Business Mailing Address
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Address Line | 710 SUNSET DR
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City | LA GRANDE
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State | OR
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Zip | 97850-1200
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Country | US
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Telephone | 541-663-3000
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Fax | 541-975-5115
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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 | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 9300627
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | M-11620
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | MD156467
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License Number State | OR
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