Individual
LESA MARIE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
14 RAINTREE CT, IRMO, SC 29063-9431
(417) 459-3020
Mailing address
14 RAINTREE CT, IRMO, SC 29063-9431
(417) 459-3020
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
23640
SC
Other
Enumeration date
08/28/2020
Last updated
08/28/2020
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