Provider Demographics
NPI:1477633980
Name:JACKSON, LEROY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:THOMAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 CHURCHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5205
Mailing Address - Country:US
Mailing Address - Phone:757-484-7822
Mailing Address - Fax:757-484-7362
Practice Address - Street 1:3205 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5205
Practice Address - Country:US
Practice Address - Phone:757-484-7822
Practice Address - Fax:757-484-7362
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406300207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALBLUE CROSSOther51109153
AL1477633980OtherNPI
ALBLUE CROSSOther51109153