Provider Demographics
NPI:1326471798
Name:JACKSON, JULIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:YULIYA
Other - Middle Name:
Other - Last Name:LEOKUMOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1 WASHINGTON SQUARE VILLAGE
Mailing Address - Street 2:14I
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012
Mailing Address - Country:US
Mailing Address - Phone:646-643-0378
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON SQUARE VILLAGE
Practice Address - Street 2:14I
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012
Practice Address - Country:US
Practice Address - Phone:646-643-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist