MEDICARE: TAWANNA C JACKSON MSP,CCC-SLP

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	SLP005500	GA

General Provider Information

NPI Number	:	1790841450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAWANNA C JACKSON MSP,CCC-SLP

Provider Business Mailing Address
First Line	:	8075 MALL PKWY
Second Line	:	SUITE 101-332
City	:	LITHONIA
State	:	GA
Zip	:	30038-6993
Country	:	US
Telephone Number	:	770-323-3002
Fax Number	:

Provider Business Practice Location Address
First Line	:	8075 MALL PKWY
Second Line	:	SUITE 101-332
City	:	LITHONIA
State	:	GA
Zip	:	30038-6993
Country	:	US
Telephone Number	:	770-323-3002
Fax Number	:

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/09/2007

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Directions to “ TAWANNA C JACKSON MSP,CCC-SLP” Practice Location

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