Provider Demographics
NPI:1457591455
Name:JACKSON, JERROLD J (SLP)
Entity Type:Individual
Prefix:MR
First Name:JERROLD
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 BRAY ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-6058
Mailing Address - Country:US
Mailing Address - Phone:972-802-1176
Mailing Address - Fax:
Practice Address - Street 1:1231 GREENWAY DR STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038
Practice Address - Country:US
Practice Address - Phone:972-871-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI46-31868OtherUNITED HEALTHCARE INSURANCE
MI40-4702665Medicaid