Basic Information
Provider Information
NPI: 1760823496
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: LEIA
MiddleName: NICOLE
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11245 WEST RD
Address2: APT #138A
City: HOUSTON
State: TX
PostalCode: 770654828
CountryCode: US
TelephoneNumber: 6054849836
FaxNumber:  
Practice Location
Address1: 8707 SPRING CYPRESS RD
Address2: SUITE A
City: SPRING
State: TX
PostalCode: 773793330
CountryCode: US
TelephoneNumber: 2813201150
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/10/2013
LastUpdateDate: 07/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X29290TXY Dental ProvidersDentist 

No ID Information.


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