Provider Demographics
NPI:1477818342
Name:JACKSON, KENDALL (SLP)
Entity Type:Individual
Prefix:MS
First Name:KENDALL
Middle Name:
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 1:3460 SOMERSET TRL SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7935
Mailing Address - Country:US
Mailing Address - Phone:864-323-7445
Mailing Address - Fax:
Practice Address - Street 1:3485 N DESERT DR STE 105
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5724
Practice Address - Country:US
Practice Address - Phone:678-724-7033
Practice Address - Fax:678-302-7357
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008103235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126519GMedicaid