Provider Demographics
NPI:1639379530
Name:JACKSON, LESLIE (MAS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21649 SHAW ST
Mailing Address - Street 2:21649 SHAW STREET
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-4803
Mailing Address - Country:US
Mailing Address - Phone:661-256-7208
Mailing Address - Fax:661-256-7209
Practice Address - Street 1:2689 SIERRA HWY
Practice Address - Street 2:
Practice Address - City:ROSAMOND
Practice Address - State:CA
Practice Address - Zip Code:93560-6053
Practice Address - Country:US
Practice Address - Phone:661-256-7208
Practice Address - Fax:661-256-7209
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator