Provider Demographics
NPI:1588730733
Name:LESCH, JACK W (M D)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:LESCH
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SILVERSTRAND
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4100
Mailing Address - Country:US
Mailing Address - Phone:281-757-7758
Mailing Address - Fax:
Practice Address - Street 1:34 SILVERSTRAND
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-4100
Practice Address - Country:US
Practice Address - Phone:281-757-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE-5402OtherSTATE LICENSE NUMBER
TXC18340Medicare UPIN