Provider Demographics
NPI:1760643134
Name:JACKSON, STEVEN I (MED CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:
Last Name:JACKSON
Suffix:I
Gender:M
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 1:100 MONIE LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1560
Mailing Address - Country:US
Mailing Address - Phone:919-821-1822
Mailing Address - Fax:919-829-3735
Practice Address - Street 1:100 MONIE LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1560
Practice Address - Country:US
Practice Address - Phone:919-821-1822
Practice Address - Fax:919-829-3735
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist