Provider Demographics
NPI:1760823496
Name:JACKSON, LEIA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEIA
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11245 WEST RD
Mailing Address - Street 2:APT #138A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4828
Mailing Address - Country:US
Mailing Address - Phone:605-484-9836
Mailing Address - Fax:
Practice Address - Street 1:8707 SPRING CYPRESS RD
Practice Address - Street 2:SUITE A
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3330
Practice Address - Country:US
Practice Address - Phone:281-320-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist