Provider Demographics
NPI:1083483697
Name:JACKSON, ELIZABETH EILEEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:EILEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7784 INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70820-7006
Mailing Address - Country:US
Mailing Address - Phone:225-343-4232
Mailing Address - Fax:
Practice Address - Street 1:7784 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70820-7006
Practice Address - Country:US
Practice Address - Phone:225-343-4232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist