Provider Demographics
NPI:1558920272
Name:JACKSON, MADISON (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 GOLF AND SEA BLVD
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6152 DELANCEY STATION ST STE 205
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4206
Practice Address - Country:US
Practice Address - Phone:813-616-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist