Provider Demographics
NPI:1972760171
Name:JACKSON, JENNIFER NICOLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 HIGH ST
Mailing Address - Street 2:PO BOX 126
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1863
Mailing Address - Country:US
Mailing Address - Phone:781-329-2262
Mailing Address - Fax:781-329-2207
Practice Address - Street 1:597 HIGH ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1863
Practice Address - Country:US
Practice Address - Phone:781-329-2262
Practice Address - Fax:781-329-2207
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13065235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist