Provider Demographics
NPI:1902161243
Name:JACKSON, HOWARD LESLIE (PT)
Entity type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:LESLIE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 KENNEDY PL
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-1611
Mailing Address - Country:US
Mailing Address - Phone:914-506-0262
Mailing Address - Fax:
Practice Address - Street 1:7801 AIRPORT PULLING RD N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-1717
Practice Address - Country:US
Practice Address - Phone:239-566-2817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 18310320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities