Provider Demographics
NPI:1326286964
Name:JACKSON, LESLEY TYESHA (FNP)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:TYESHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3398
Mailing Address - Country:US
Mailing Address - Phone:800-379-1600
Mailing Address - Fax:
Practice Address - Street 1:900 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3398
Practice Address - Country:US
Practice Address - Phone:800-379-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244746163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse