Provider Demographics
NPI:1487367421
Name:JACKSON, LESLIE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6277 N 900 W 27
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:IN
Mailing Address - Zip Code:46919-9376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1393 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1913
Practice Address - Country:US
Practice Address - Phone:765-660-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003280A225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist