| Organization Name: | LEROY R JACKSON JR DDS PLLC |
| NPI Number: | 1497010136 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ELLEN ROSSBERG (OWNER) |
| Mailing Address: | 215 E 5th Ave Ranson |
| State: | WV US |
| Postal Code: | 254381613 |
| Phone Number: | 3047258660 |
| Fax Number: | 3047287519 |
| NPI Enumeration Date: | 07/09/2012 |
| NPI Last Update Date: | 07/09/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |