Provider Demographics
NPI:1336475375
Name:JACKSON, ELIZABETH C (SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11535 CARMEL COMMONS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5313
Mailing Address - Country:US
Mailing Address - Phone:704-541-3737
Mailing Address - Fax:704-540-9199
Practice Address - Street 1:11535 CARMEL COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5313
Practice Address - Country:US
Practice Address - Phone:704-541-3737
Practice Address - Fax:704-540-9199
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12121284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist