Provider Demographics
NPI:1245582741
Name:JACKSON, TERESA B (HIS)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:
Practice Address - Street 1:2001 LINCOLN DR W
Practice Address - Street 2:SUITE E
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1531
Practice Address - Country:US
Practice Address - Phone:856-596-9670
Practice Address - Fax:856-985-6302
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ237600000X
NJ25MG00116200237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter