Provider Demographics
NPI:1790841450
Name:JACKSON, TAWANNA C (MSP,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSP,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8075 MALL PKWY
Mailing Address - Street 2:SUITE 101-332
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6993
Mailing Address - Country:US
Mailing Address - Phone:770-323-3002
Mailing Address - Fax:
Practice Address - Street 1:8075 MALL PKWY
Practice Address - Street 2:SUITE 101-332
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6993
Practice Address - Country:US
Practice Address - Phone:770-323-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist