Provider Demographics
NPI:1659923571
Name:RICHARDSON-JACKSON, KEA O (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KEA
Middle Name:O
Last Name:RICHARDSON-JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KEA
Other - Middle Name:O
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1825 BATH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4613
Mailing Address - Country:US
Mailing Address - Phone:917-748-0674
Mailing Address - Fax:
Practice Address - Street 1:1825 BATH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4613
Practice Address - Country:US
Practice Address - Phone:718-621-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist