Provider Demographics
NPI:1326201922
Name:JACKSON, SARAH NICHOLE (AUD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:NICHOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 BRIARGATE PKWY
Mailing Address - Street 2:B520
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7804
Mailing Address - Country:US
Mailing Address - Phone:720-777-6800
Mailing Address - Fax:720-777-7299
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:B030
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-6800
Practice Address - Fax:720-777-7299
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO534231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57155887Medicaid