Provider Demographics
NPI:1114973559
Name:JACKSON, TARA MICHELE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELE
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 1:3403 LINDEN BERRY LANE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1300
Mailing Address - Country:US
Mailing Address - Phone:704-898-2437
Mailing Address - Fax:
Practice Address - Street 1:3403 LINDEN BERRY LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1300
Practice Address - Country:US
Practice Address - Phone:704-258-1724
Practice Address - Fax:704-598-3024
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2011-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412438Medicaid