Provider Demographics
NPI:1649320904
Name:JACKSON, LESLIE K (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:K
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 1:404 E MAIN CROSS ST
Mailing Address - Street 2:P O BOX 318
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2656
Mailing Address - Country:US
Mailing Address - Phone:217-824-3758
Mailing Address - Fax:217-824-3758
Practice Address - Street 1:404 E MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2656
Practice Address - Country:US
Practice Address - Phone:217-824-3758
Practice Address - Fax:217-824-3758
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371403688001Medicaid
IL036072876Medicaid
IL14-8934Medicare ID - Type Unspecified
IL608210Medicare ID - Type Unspecified
IL036072876Medicaid