Provider Demographics
NPI:1548587280
Name:JACKSON, LISA GIBSON (MS CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GIBSON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15642 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-3028
Mailing Address - Country:US
Mailing Address - Phone:708-841-7446
Mailing Address - Fax:
Practice Address - Street 1:15642 MADISON AVE
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-3028
Practice Address - Country:US
Practice Address - Phone:708-841-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146002827235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist