Provider Demographics
NPI:1700840162
Name:JACKSON, JEAN LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:LEIGH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493
Mailing Address - Country:US
Mailing Address - Phone:781-893-8896
Mailing Address - Fax:
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462
Practice Address - Country:US
Practice Address - Phone:617-243-6040
Practice Address - Fax:617-243-6924
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212899207PP0204X
RI07406207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
212899OtherTUFTS
J25711OtherBLUE SHIELD
MA3204821Medicaid
5480OtherHP
A34949Medicare ID - Type Unspecified
MA3204821Medicaid