Provider Demographics
NPI:1982065710
Name:JACKSON, TONYA ELAINE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 CHASTAIN PARC DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-7662
Mailing Address - Country:US
Mailing Address - Phone:704-804-8577
Mailing Address - Fax:980-207-2380
Practice Address - Street 1:11204 CHASTAIN PARC DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7662
Practice Address - Country:US
Practice Address - Phone:704-804-8577
Practice Address - Fax:980-207-2380
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist