Provider Demographics
NPI:1710130836
Name:JACKSON, MICHELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:415 CURTIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17702-7249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 CURTIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-7249
Practice Address - Country:US
Practice Address - Phone:570-323-3758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL003721L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist