Provider Demographics
NPI:1295868131
Name:JACKSON, MARI ANN (ST)
Entity Type:Individual
Prefix:MRS
First Name:MARI
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WESTFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1323
Mailing Address - Country:US
Mailing Address - Phone:317-776-7225
Mailing Address - Fax:317-776-7226
Practice Address - Street 1:601 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1323
Practice Address - Country:US
Practice Address - Phone:317-776-7225
Practice Address - Fax:317-776-7226
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist