Provider Demographics
NPI:1669900239
Name:JACKSON, LESLIE J (LCSW)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:J
Other - Last Name:KAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:650 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1517
Mailing Address - Country:US
Mailing Address - Phone:718-596-9800
Mailing Address - Fax:718-596-9889
Practice Address - Street 1:650 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1517
Practice Address - Country:US
Practice Address - Phone:718-834-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0848701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05160852Medicaid