Provider Demographics
NPI:1295203529
Name:JACKSON CARBINE, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JACKSON CARBINE
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 1:396 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:396 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:CHICKAMAUGA
Practice Address - State:GA
Practice Address - Zip Code:30707-4500
Practice Address - Country:US
Practice Address - Phone:423-762-4754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant