Provider Demographics
NPI:1184273153
Name:JACKSON, KOLBY (SLP)
Entity type:Individual
Prefix:
First Name:KOLBY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ROYAL ROSE DR
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-3377
Mailing Address - Country:US
Mailing Address - Phone:832-304-4524
Mailing Address - Fax:
Practice Address - Street 1:46 ROYAL ROSE DR
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-3377
Practice Address - Country:US
Practice Address - Phone:832-385-3140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist