Provider Demographics
NPI:1154549715
Name:JACKSON, LEONARD VICTOR JR (DDS)
Entity type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:VICTOR
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N. 12TH STREET
Mailing Address - Street 2:SUITE #406
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-2977
Mailing Address - Fax:804-828-3159
Practice Address - Street 1:520 NORTH 12TH STREET
Practice Address - Street 2:SUITE #406
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-2977
Practice Address - Fax:804-828-3159
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411640122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist