Provider Demographics
NPI:1497398218
Name:JACKSON, LESLIE DENISE (CNM)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:DENISE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2906 FRANCISCAN DR APT 1725
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2576
Mailing Address - Country:US
Mailing Address - Phone:734-444-9098
Mailing Address - Fax:
Practice Address - Street 1:1001 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2513
Practice Address - Country:US
Practice Address - Phone:817-962-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife