Provider Demographics
NPI:1558849075
Name:JACKSON, MARIA ELENA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELENA
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 1:257 E BELLEVUE RD STE 274
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-2304
Mailing Address - Country:US
Mailing Address - Phone:209-614-6731
Mailing Address - Fax:
Practice Address - Street 1:970 TRAVERTINE WAY
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4486
Practice Address - Country:US
Practice Address - Phone:209-614-6731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist