Provider Demographics
NPI:1154459527
Name:JACKSON, LEONARD JR
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 WYMAN ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3464
Mailing Address - Country:US
Mailing Address - Phone:510-261-1027
Mailing Address - Fax:510-261-5757
Practice Address - Street 1:4368 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2529
Practice Address - Country:US
Practice Address - Phone:510-531-3111
Practice Address - Fax:510-531-8498
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health