Provider Demographics
NPI:1861668857
Name:JACKSON, RAE LYNN (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:RAE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA,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 N SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-1174
Mailing Address - Country:US
Mailing Address - Phone:815-747-3117
Mailing Address - Fax:815-747-3827
Practice Address - Street 1:100 N SCHOOL RD
Practice Address - Street 2:
Practice Address - City:EAST DUBUQUE
Practice Address - State:IL
Practice Address - Zip Code:61025-1174
Practice Address - Country:US
Practice Address - Phone:815-747-3117
Practice Address - Fax:815-747-3827
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist