Provider Demographics
NPI:1407042393
Name:JACKSON, ELEANOR JAYNE (SLP)
Entity Type:Individual
Prefix:MISS
First Name:ELEANOR
Middle Name:JAYNE
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 1:3490 EDISON RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1526
Mailing Address - Country:US
Mailing Address - Phone:216-291-2850
Mailing Address - Fax:216-291-2850
Practice Address - Street 1:5273 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1626
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-2341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0842995Medicaid
OH000000217475Other'ANTHEM BLUE CROSS AND B'
OH366587Medicare PIN