Basic Information
| Provider Information | |||||||||
| NPI: | 1366407496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63111 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306551869 | ||||||||
| FaxNumber: | 6109560009 | ||||||||
| Practice Location | |||||||||
| Address1: | 3010 TRENWEST DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369705300 | ||||||||
| FaxNumber: | 3369705298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME73224 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301059418 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2020-03986 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.