Provider Demographics
NPI:1033261946
Name:JACKSON, ANGELA DAWN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:ANGIE
Other - Middle Name:DAWN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:603 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-3954
Mailing Address - Country:US
Mailing Address - Phone:573-471-6653
Mailing Address - Fax:
Practice Address - Street 1:603 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3954
Practice Address - Country:US
Practice Address - Phone:573-471-6653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist