Provider Demographics
NPI:1982926028
Name:JACKSON, KELLEY ANNE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 TEWKSBURY LN NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2220
Mailing Address - Country:US
Mailing Address - Phone:321-266-4886
Mailing Address - Fax:
Practice Address - Street 1:472 TEWKSBURY LN NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2220
Practice Address - Country:US
Practice Address - Phone:321-266-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist