Provider Demographics
NPI:1528397395
Name:JACKSON, LASHUNDA DENISE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LASHUNDA
Middle Name:DENISE
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 1:1862 HIGHWAY 278 E
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-9192
Mailing Address - Country:US
Mailing Address - Phone:870-367-1994
Mailing Address - Fax:
Practice Address - Street 1:1862 HIGHWAY 278 E
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-9192
Practice Address - Country:US
Practice Address - Phone:870-367-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP #1214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133472721Medicaid