NPIMap

Individual provider Active NPI

Leland Jay Jackson, MD

  • Family Medicine Physician
  • Camillus, NY
National Provider Identifier
1386616472
Registry record updated Mar 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
171536 Issued in NY
Practice address
5006 W Genesee St
Camillus, NY 13031-2326
Phone
(315) 234-2342
Fax
(315) 234-0697
NPI assigned
Feb 3, 2006
Last updated
Mar 7, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 171536 NY Primary

Addresses

Primary practice location

5006 W Genesee St
Camillus, NY 13031-2326

Mailing address

5006 W Genesee St
Camillus, NY 13031-2326
Phone (315) 234-2342

Other identifiers 2

IdentifierTypeStateIssuer
01348347MedicaidNY
171536OtherNYSTATE LICENSE NUMBER

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20111221000665 NY Practitioner - Family Practice 8022070333 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Arizona College of Medicine, 1986
Medicare assignment
May accept Medicare assignment
Telehealth
Offers telehealth services
Group practices
Select PT, OT and SLP Rehabilitation Ny, PLLCGroup PAC ID 3870986656, 261 clinicians
Fairmount Family Medicine PLLCGroup PAC ID 0941262240, 2 clinicians

Practice addresses (Care Compare)

125 Harry Howard Ave
Hudson, NY 12534-1601
Phone (800) 479-7695

5006 W Genesee St
Camillus, NY 13031-2326

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138924800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1386616472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5006 W GENESEE ST",
            "city": "CAMILLUS",
            "state": "NY",
            "postal_code": "130312326",
            "telephone_number": "315-234-2342",
            "fax_number": "315-234-0697"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5006 W GENESEE ST",
            "city": "CAMILLUS",
            "state": "NY",
            "postal_code": "130312326",
            "telephone_number": "315-234-2342",
            "fax_number": "315-234-0697"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "LELAND",
        "middle_name": "JAY",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-03",
        "last_updated": "2023-03-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NY",
            "license": "171536",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01348347",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE NUMBER",
            "identifier": "171536",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Camillus, NY

Sources for this page

Verify at the official NPI Registry.