Provider Demographics
NPI:1861875486
Name:JACKSON, JESSICA DAVIS (AUD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAVIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PEARL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2866
Mailing Address - Country:US
Mailing Address - Phone:508-588-8034
Mailing Address - Fax:508-897-0475
Practice Address - Street 1:35 PEARL ST STE 100
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2866
Practice Address - Country:US
Practice Address - Phone:508-588-8034
Practice Address - Fax:508-897-0475
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006419231H00000X
MAAUD100190231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
13592238OtherCAQH
PA1030512850001Medicaid