Provider Demographics
NPI:1912324229
Name:JACKSON, DONNA (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 W MAPLE LEAF RD
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8138
Mailing Address - Country:US
Mailing Address - Phone:606-564-8243
Mailing Address - Fax:
Practice Address - Street 1:141 LLOYD RD
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-8974
Practice Address - Country:US
Practice Address - Phone:937-544-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5533235Z00000X
KY1324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist