Provider Demographics
NPI:1568555845
Name:JACKSON, LENLEY BRADFORD (MD)
Entity type:Individual
Prefix:DR
First Name:LENLEY
Middle Name:BRADFORD
Last Name:JACKSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1888 KALAKAUA AVE STE C312
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1550
Mailing Address - Country:US
Mailing Address - Phone:808-391-6691
Mailing Address - Fax:
Practice Address - Street 1:3100 W CHRISTOFFERSEN PKWY
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-9547
Practice Address - Country:US
Practice Address - Phone:209-632-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15431207P00000X
CAA87877207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA2264OtherRAILROAD MEDICARE GROUP PTAN
ILR00965OtherMEDICARE INDIVIDUAL #
ILP00601866OtherRAILROAD MEDICARE MEMBER PTAN
IL036119364Medicaid
IL833120OtherMEDICARE GROUP #
ILCA2264OtherRAILROAD MEDICARE GROUP PTAN
H39535Medicare UPIN