Provider Demographics
NPI:1972365161
Name:DAVIS, JACQUELINE LESKO
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LESKO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18527 CARNEGIE OVERLOOK BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-6012
Mailing Address - Country:US
Mailing Address - Phone:704-301-6360
Mailing Address - Fax:
Practice Address - Street 1:18527 CARNEGIE OVERLOOK BLVD
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-6012
Practice Address - Country:US
Practice Address - Phone:704-301-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2131225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist