Provider Demographics
NPI:1336552892
Name:JACKSON, LESLEY M (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1550
Mailing Address - Country:US
Mailing Address - Phone:606-784-6641
Mailing Address - Fax:606-783-6847
Practice Address - Street 1:316 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1550
Practice Address - Country:US
Practice Address - Phone:606-784-3771
Practice Address - Fax:606-783-6847
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36869207Q00000X
KYTP037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTP037OtherMEDICAL LICENSE