Provider Demographics
NPI:1285622175
Name:JACKSON, LEON S (MD)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7099
Mailing Address - Country:US
Mailing Address - Phone:608-788-8103
Mailing Address - Fax:608-788-8799
Practice Address - Street 1:118 E HASKELL ST
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-3247
Practice Address - Country:US
Practice Address - Phone:608-788-8103
Practice Address - Fax:608-788-8799
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV113482085R0202X
CAG684302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505784Medicaid
NV100549Medicare ID - Type Unspecified36908
NV100550Medicare ID - Type Unspecified36909
NV100548Medicare ID - Type Unspecified36907
NV100505784Medicaid
NVF03597Medicare UPIN