Provider Demographics
NPI:1417378787
Name:JACKSON, DIANA BELTRAN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:BELTRAN
Last Name:JACKSON
Suffix:
Gender:F
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 1:3355 BOCA CHICA BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-4201
Mailing Address - Country:US
Mailing Address - Phone:956-546-4009
Mailing Address - Fax:
Practice Address - Street 1:3355 BOCA CHICA BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-4201
Practice Address - Country:US
Practice Address - Phone:956-546-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112130235Z00000X
AZTSLP4660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist