Healthcare Provider Details

I. General information

NPI: 1114796018
Provider Name (Legal Business Name): EMILY ELISE JACKSON SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 190TH ST STE 2300
GARDENA CA
90248-4350
US

IV. Provider business mailing address

1149 W 190TH ST STE 2300
GARDENA CA
90248-4350
US

V. Phone/Fax

Practice location:
  • Phone: 310-892-5812
  • Fax:
Mailing address:
  • Phone: 562-884-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: