Provider Demographics
NPI:1093263964
Name:JACKSON, LEONNA (LISW)
Entity type:Individual
Prefix:
First Name:LEONNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 OAK ALLEY CT STE 304
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1365
Mailing Address - Country:US
Mailing Address - Phone:419-870-9461
Mailing Address - Fax:567-429-0185
Practice Address - Street 1:3454 OAK ALLEY CT STE 304
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1365
Practice Address - Country:US
Practice Address - Phone:419-870-9461
Practice Address - Fax:567-429-0185
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OHS.1500013104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health