Provider Demographics
NPI:1942436829
Name:JACKSON, SHERLEY LAURIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHERLEY
Middle Name:LAURIN
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 1:4047 MADISON ACRES DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4375
Mailing Address - Country:US
Mailing Address - Phone:828-399-0979
Mailing Address - Fax:
Practice Address - Street 1:300 LESTER MILL RD
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-5306
Practice Address - Country:US
Practice Address - Phone:404-480-0489
Practice Address - Fax:678-586-5828
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30732235Z00000X
LA7074235Z00000X
GA010047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003230088AMedicaid