Provider Demographics
NPI:1952990806
Name:MCKISSON, MADISON A (MS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:A
Last Name:MCKISSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-0718
Mailing Address - Country:US
Mailing Address - Phone:870-243-2132
Mailing Address - Fax:
Practice Address - Street 1:140 LINWOOD DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4077
Practice Address - Country:US
Practice Address - Phone:870-520-8761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist