Provider Demographics
NPI:1861753048
Name:JACKSON, LESLIE L (MED, OT/L, FAOTA)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED, OT/L, FAOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 S KING DR
Mailing Address - Street 2:DH 132
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1501
Mailing Address - Country:US
Mailing Address - Phone:773-995-2368
Mailing Address - Fax:
Practice Address - Street 1:9501 S KING DR
Practice Address - Street 2:DH 132
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1501
Practice Address - Country:US
Practice Address - Phone:773-995-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.000012225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist