Provider Demographics
NPI:1881931863
Name:JACKSON, MICHELLE N (SPEECH PATHOLOGIST)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WELAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 MEDICAL DRIVE
Mailing Address - Street 2:LIFESPAN THERAPY
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2923
Mailing Address - Country:US
Mailing Address - Phone:317-817-8874
Mailing Address - Fax:812-257-0039
Practice Address - Street 1:118 MEDICAL DRIVE
Practice Address - Street 2:LIFESPAN THERAPY
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2923
Practice Address - Country:US
Practice Address - Phone:317-817-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002415A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist