Provider Demographics
NPI:1164605697
Name:JACKSON, NATALIE ALEECE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:ALEECE
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 1:6589 W STONES CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9117
Mailing Address - Country:US
Mailing Address - Phone:214-223-0142
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:888-543-2289
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004557A235Z00000X
TX19716235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist