Provider Demographics
NPI:1164077921
Name:JACKSON, LONDYN ANDREA
Entity Type:Individual
Prefix:
First Name:LONDYN
Middle Name:ANDREA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4059 TARPON LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-2332
Mailing Address - Country:US
Mailing Address - Phone:703-600-9302
Mailing Address - Fax:
Practice Address - Street 1:15500 BENITA FITZGERALD DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-8523
Practice Address - Country:US
Practice Address - Phone:703-583-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000315235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist