MEDICARE: GLENDA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	12-7491	MD
2	235Z00000X	Speech-Language Pathologist	0517	MD

General Provider Information

NPI Number	:	1104399823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDA JACKSON

Provider Business Mailing Address
First Line	:	2100 CEDAR DR
Second Line	:
City	:	EDGEWOOD
State	:	MD
Zip	:	21040-2502
Country	:	US
Telephone Number	:	410-612-1540
Fax Number	:	410-612-2013

Provider Business Practice Location Address
First Line	:	2100 CEDAR DR
Second Line	:
City	:	EDGEWOOD
State	:	MD
Zip	:	21040-2502
Country	:	US
Telephone Number	:	410-612-1540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	11/13/2019

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Directions to “ GLENDA JACKSON ” Practice Location

Language	Start Address	Practice Location

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