Provider Demographics
NPI:1295112654
Name:VARGAS-JACKSON, CAROLYN F (CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:F
Last Name:VARGAS-JACKSON
Suffix:
Gender:F
Credentials: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:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0052
Mailing Address - Country:US
Mailing Address - Phone:774-218-9438
Mailing Address - Fax:
Practice Address - Street 1:3417 SEVEN OAKS RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4261
Practice Address - Country:US
Practice Address - Phone:804-822-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist