Provider Demographics
NPI:1023564200
Name:JACKSON, LORRAINE T (SLP/CCC)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP/CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9167
Mailing Address - Country:US
Mailing Address - Phone:706-881-0901
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BLDG. 400 STE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:866-587-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist