Provider Demographics
NPI:1871840694
Name:JACKSON, KATIE ANNE (MA CCC-SLP/BCBA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA CCC-SLP/BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11344 COLOMA RD STE 810
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4465
Mailing Address - Country:US
Mailing Address - Phone:916-631-0428
Mailing Address - Fax:
Practice Address - Street 1:11344 COLOMA RD STE 810
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4465
Practice Address - Country:US
Practice Address - Phone:916-631-0428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA19945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty