Provider Demographics
NPI:1659892768
Name:WAXTER, JAIME HUDSON (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:HUDSON
Last Name:WAXTER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 MAYORS WAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8065
Mailing Address - Country:US
Mailing Address - Phone:706-614-4707
Mailing Address - Fax:
Practice Address - Street 1:1071 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6073
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:678-374-4855
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist