Provider Demographics
NPI:1033545041
Name:JACKSON, MARIDYTH MARGINIA (MS)
Entity Type:Individual
Prefix:MISS
First Name:MARIDYTH
Middle Name:MARGINIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 10TH WAY N
Mailing Address - Street 2:#3307
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1510
Mailing Address - Country:US
Mailing Address - Phone:559-288-0713
Mailing Address - Fax:
Practice Address - Street 1:11901 10TH WAY N
Practice Address - Street 2:#3307
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1510
Practice Address - Country:US
Practice Address - Phone:559-288-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist