Provider Demographics
NPI:1982902516
Name:JACKSON, TRACY ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
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 1:6395 POLO CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-5716
Mailing Address - Country:US
Mailing Address - Phone:561-706-5646
Mailing Address - Fax:
Practice Address - Street 1:6395 POLO CLUB DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-5716
Practice Address - Country:US
Practice Address - Phone:561-706-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006097235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01069022OtherASHA (SPEECH-LANGUAGE CERTIFICATION)