Provider Demographics
NPI:1922779172
Name:JACKSON, LEANNA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9491
Mailing Address - Country:US
Mailing Address - Phone:270-839-8303
Mailing Address - Fax:
Practice Address - Street 1:2509 MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9491
Practice Address - Country:US
Practice Address - Phone:270-839-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily