Provider Demographics
NPI:1952476822
Name:JACKSON, PETRINA F (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:PETRINA
Middle Name:F
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 1:12224 FAIRWAY CIR
Mailing Address - Street 2:UNIT A
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3611
Mailing Address - Country:US
Mailing Address - Phone:708-824-9524
Mailing Address - Fax:708-824-9524
Practice Address - Street 1:12224 FAIRWAY CIR
Practice Address - Street 2:UNIT A
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-3611
Practice Address - Country:US
Practice Address - Phone:708-824-9524
Practice Address - Fax:708-824-9524
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist