Provider Demographics
NPI:1457051898
Name:JACKSON-VALLADE, LESLIE (LDN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JACKSON-VALLADE
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 PENTLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-9242
Mailing Address - Country:US
Mailing Address - Phone:443-519-9388
Mailing Address - Fax:
Practice Address - Street 1:3851 PENTLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-9242
Practice Address - Country:US
Practice Address - Phone:443-519-9388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5990133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist