Provider Demographics
NPI:1003540261
Name:JACKSON SPEECH THERAPY SERVICES
Entity Type:Organization
Organization Name:JACKSON SPEECH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/OWNER/SLP
Authorized Official - Prefix:MS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:M ED CCC-SLP
Authorized Official - Phone:706-224-1178
Mailing Address - Street 1:380 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-2092
Mailing Address - Country:US
Mailing Address - Phone:706-224-1178
Mailing Address - Fax:
Practice Address - Street 1:380 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-2092
Practice Address - Country:US
Practice Address - Phone:706-224-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty