Individual
DR. LESLIE K JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
404 E MAIN CROSS ST, TAYLORVILLE, IL 62568-2656
(217) 824-3758
(217) 824-3758
Mailing address
404 E MAIN CROSS ST, P O BOX 318, TAYLORVILLE, IL 62568-2656
(217) 824-3758
(217) 824-3758
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036072876
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036072876
—
IL
05
—
371403688001
—
IL
Enumeration date
01/11/2007
Last updated
04/13/2010
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