Provider Demographics
NPI:1902205693
Name:JACKSON, LORI JANE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 WHITE BLUFF RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4668
Mailing Address - Country:US
Mailing Address - Phone:912-335-8486
Mailing Address - Fax:912-335-3528
Practice Address - Street 1:9100 WHITE BLUFF RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4668
Practice Address - Country:US
Practice Address - Phone:912-335-8486
Practice Address - Fax:912-335-3528
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2015-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008987235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist