Provider Demographics
NPI:1194013284
Name:JACKSON, KAREN C (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:C
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 1:7449 HEATHERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5292
Mailing Address - Country:US
Mailing Address - Phone:724-413-4024
Mailing Address - Fax:703-822-0063
Practice Address - Street 1:7449 HEATHERFIELD LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5292
Practice Address - Country:US
Practice Address - Phone:724-413-4024
Practice Address - Fax:703-822-0063
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004751235Z00000X
PASL004095235Z00000X
NY007838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist