Provider Demographics
NPI:1255505459
Name:JACKSON, LEANNE KOLNICK
Entity Type:Individual
Prefix:DR
First Name:LEANNE
Middle Name:KOLNICK
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 HOLCOMBE BLVD
Mailing Address - Street 2:ECL 110. MICHEAL E DEBAKEY VA MEDICAL CENTER
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4211
Mailing Address - Country:US
Mailing Address - Phone:713-791-1414
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD
Practice Address - Street 2:110 ECL. MICHEAL E DEBAKEY VA MEDICAL CENTER
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:713-791-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46843207R00000X
390200000X
TXQ4140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program