Provider Demographics
NPI:1972690774
Name:JACKSON, LESLIE W (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:K
Other - Last Name:WILGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:710 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1200
Mailing Address - Country:US
Mailing Address - Phone:541-663-3000
Mailing Address - Fax:541-975-5115
Practice Address - Street 1:710 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1200
Practice Address - Country:US
Practice Address - Phone:541-663-3000
Practice Address - Fax:541-975-5115
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300627207RR0500X
IDM-11620207RR0500X
ORMD156467207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology