Provider Demographics
NPI:1356496707
Name:JACKSON, SCOTT BRYAN (MS, CCC SLP)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:BRYAN
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 1:235 BLUE POINT AVE
Mailing Address - Street 2:LITTLE ANGELS CENTER
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1203
Mailing Address - Country:US
Mailing Address - Phone:631-363-5794
Mailing Address - Fax:631-363-8046
Practice Address - Street 1:235 BLUE POINT AVE
Practice Address - Street 2:LITTLE ANGELS CENTER
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1203
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:631-363-8046
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016099-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist