Provider Demographics
NPI:1306837042
Name:JACKSON, LEE SA B (MD)
Entity Type:Individual
Prefix:
First Name:LEE SA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEE SA
Other - Middle Name:B
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4824 E BASELINE RD
Mailing Address - Street 2:STE 110
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4678
Mailing Address - Country:US
Mailing Address - Phone:480-615-2020
Mailing Address - Fax:480-219-9957
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4676
Practice Address - Country:US
Practice Address - Phone:480-615-2020
Practice Address - Fax:480-219-9957
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25793207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ404731Medicaid
AZG28231Medicare UPIN