Provider Demographics
NPI:1073641213
Name:JACKSON, ROBERTA A (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N. RIVERPOINT BLVD
Mailing Address - Street 2:BOX V
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1675
Mailing Address - Country:US
Mailing Address - Phone:509-358-7584
Mailing Address - Fax:509-368-6890
Practice Address - Street 1:310 N. RIVERPOINT BLVD
Practice Address - Street 2:BOX V
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1675
Practice Address - Country:US
Practice Address - Phone:509-358-7584
Practice Address - Fax:509-368-6890
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist