MEDICARE: KATHRYN JACKSON ALTENBACH

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366942500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN JACKSON ALTENBACH

Provider Business Mailing Address
First Line	:	235 9TH AVE N
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-7142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13453 N MAIN ST STE 401
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2774
Country	:	US
Telephone Number	:	904-249-8893
Fax Number	:

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

Provider Enumeration Date	:	02/14/2018
Last Update Date	:	07/22/2019

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Directions to “ KATHRYN JACKSON ALTENBACH ” Practice Location

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