Healthcare Provider Details

I. General information

NPI: 1376857037
Provider Name (Legal Business Name): DARLASUE KATRICE JACKSON SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 SPRINGFIELD BLVD
BOWLING GREEN KY
42104-5517
US

IV. Provider business mailing address

310 CAMINO DE LA PLACITA
TAOS NM
87571-5951
US

V. Phone/Fax

Practice location:
  • Phone: 270-612-0700
  • Fax:
Mailing address:
  • Phone: 575-758-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-2023-0263
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3803
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: