MEDICARE: LESLIE DENISE JACKSON CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367A00000X	Advanced Practice Midwife		TX

General Provider Information

NPI Number	:	1497398218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE DENISE JACKSON CNM

Provider Business Mailing Address
First Line	:	4708 ENGLISHTOWN DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-1880
Country	:	US
Telephone Number	:	734-444-9098
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 W RANDOL MILL RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-2513
Country	:	US
Telephone Number	:	817-962-0004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	02/04/2025

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