Provider Demographics
NPI:1790005791
Name:JACKSON, DEMETRIA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials: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:PO BOX 2246
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-2246
Mailing Address - Country:US
Mailing Address - Phone:912-689-4382
Mailing Address - Fax:888-875-2884
Practice Address - Street 1:157 CORAL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31523-8951
Practice Address - Country:US
Practice Address - Phone:912-689-4382
Practice Address - Fax:888-875-2884
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007195235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA658178836AMedicaid