Provider Demographics
NPI:1457422156
Name:JACKSON, JENNIFER M (SLP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:BONGIOVANNI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:82 IRVING TER
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14223-2740
Mailing Address - Country:US
Mailing Address - Phone:716-864-1921
Mailing Address - Fax:
Practice Address - Street 1:105 CASEY RD
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-2224
Practice Address - Country:US
Practice Address - Phone:716-626-8000
Practice Address - Fax:716-626-8089
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0168021235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist