Provider Demographics
NPI:1609096965
Name:JACKSON, TERESA A (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 STATE HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1666
Mailing Address - Country:US
Mailing Address - Phone:573-359-0021
Mailing Address - Fax:573-359-6525
Practice Address - Street 1:PEMISCOT CO SPECIAL SCHOOL DISTRICT
Practice Address - Street 2:1317 STATE HIGHWAY 84
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1666
Practice Address - Country:US
Practice Address - Phone:573-359-0021
Practice Address - Fax:573-359-6525
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO464450006Medicaid