Healthcare Provider Details

I. General information

NPI: 1881598324
Provider Name (Legal Business Name): AVA JUNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PLEASANT ST
BROCKTON MA
02301-3052
US

IV. Provider business mailing address

801 PLEASANT ST
BROCKTON MA
02301-3052
US

V. Phone/Fax

Practice location:
  • Phone: 508-586-5977
  • Fax: 508-583-5847
Mailing address:
  • Phone: 508-586-5977
  • Fax: 508-583-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA100915
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: