# LEROY R JACKSON JR DDS PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1497010136
- **Authorized official:** MRS. ELLEN ROSSBERG (OWNER)
- **Authorized official phone:** (904) 725-6634

## Contact information

- **Practice address:** 215 E 5TH AVE, RANSON, WV 25438-1613
- **Practice address phone:** (304) 725-8660
- **Practice address fax:** (304) 728-7519
- **Mailing address:** 215 E 5TH AVE, RANSON, WV 25438-1613

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 07/09/2012
- **Last updated:** 07/09/2012