Provider Demographics
NPI:1083057152
Name:JACKSON, LESLIE SCHAAD (FNP-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SCHAAD
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:E
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:460 NORTHSIDE CHEROKEE BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8016
Mailing Address - Country:US
Mailing Address - Phone:770-721-9170
Mailing Address - Fax:770-721-9171
Practice Address - Street 1:10515 BELLS FERRY RD STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4204
Practice Address - Country:US
Practice Address - Phone:678-493-0752
Practice Address - Fax:678-493-2401
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003154541AMedicaid
GA003154541BMedicaid
GA003154541BMedicaid