Provider Demographics
NPI:1134833759
Name:JACKSON, ROBERT LEE KNAPP
Entity type:Individual
Prefix:
First Name:ROBERT LEE
Middle Name:KNAPP
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23634 N 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3647
Mailing Address - Country:US
Mailing Address - Phone:602-309-8821
Mailing Address - Fax:
Practice Address - Street 1:11226 N 23RD AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4830
Practice Address - Country:US
Practice Address - Phone:602-309-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA142152355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant