Provider Demographics
NPI:1356494934
Name:JACKSON, SCOTT AARON (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:AARON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 FALLEN LEAF CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-4038
Mailing Address - Country:US
Mailing Address - Phone:707-864-6445
Mailing Address - Fax:
Practice Address - Street 1:755 FALLEN LEAF CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-4038
Practice Address - Country:US
Practice Address - Phone:707-646-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist