Provider Demographics
NPI:1245292291
Name:JACKSON, LESIA TYSON (MD)
Entity type:Individual
Prefix:
First Name:LESIA
Middle Name:TYSON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LESIA
Other - Middle Name:LINDA
Other - Last Name:TYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15759
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-2459
Mailing Address - Country:US
Mailing Address - Phone:912-355-8188
Mailing Address - Fax:912-356-6970
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-355-8188
Practice Address - Fax:912-356-6970
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96003542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00391009OtherRAILROAD MEDICARE
GA52223821001OtherBCBS
SCN00354Medicaid
GA078632737AMedicaid
NC8984140Medicaid
GA30BDNNGMedicare PIN
F56032Medicare UPIN
GA078632737AMedicaid