Provider Demographics
NPI:1386616472
Name:JACKSON, LELAND JAY (MD)
Entity type:Individual
Prefix:DR
First Name:LELAND
Middle Name:JAY
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 1:5006 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2326
Mailing Address - Country:US
Mailing Address - Phone:315-234-2342
Mailing Address - Fax:315-234-0697
Practice Address - Street 1:5006 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2326
Practice Address - Country:US
Practice Address - Phone:315-234-2342
Practice Address - Fax:315-234-0697
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01348347Medicaid
NY171536OtherSTATE LICENSE NUMBER
BJ1829893OtherDEA
NYE39617Medicare UPIN