Provider Demographics
NPI:1508826835
Name:JACKSON FILSON, JENNIFER DAWN (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:JACKSON FILSON
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:JACKSON MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD, CCC-A
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2485 E WABASH ST STE 110
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041
Practice Address - Country:US
Practice Address - Phone:765-659-7400
Practice Address - Fax:765-659-7408
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002275A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300023111Medicaid
IN200340620Medicaid
IN11485690OtherCAQH NUMBER
IN9397779OtherPHCS PID NUMBER
IN815630HMedicare PIN
IN185820BMedicare PIN
IN200340620Medicaid