Provider Demographics
NPI:1275881526
Name:JACKSON, KIA NYKETTA
Entity Type:Individual
Prefix:MS
First Name:KIA
Middle Name:NYKETTA
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 1:3209 S EASTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-2931
Mailing Address - Country:US
Mailing Address - Phone:520-661-8065
Mailing Address - Fax:
Practice Address - Street 1:3209 S EASTVIEW AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-2931
Practice Address - Country:US
Practice Address - Phone:520-661-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant