Provider Demographics
NPI:1447216619
Name:JACKSON, JO ANNE (MA, CCC- SLP)
Entity Type:Individual
Prefix:MRS
First Name:JO ANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC- SLP
Other - Prefix:MRS
Other - First Name:JO ANNE
Other - Middle Name:S
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:RR 1 BOX 78
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:NM
Mailing Address - Zip Code:87747-9704
Mailing Address - Country:US
Mailing Address - Phone:505-483-5558
Mailing Address - Fax:
Practice Address - Street 1:1401 8TH ST.
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:NM
Practice Address - Zip Code:87747
Practice Address - Country:US
Practice Address - Phone:505-483-3444
Practice Address - Fax:505-483-5530
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM991235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000J2837Medicaid