=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083632467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY GREEN JACKSON S.L.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5314 MOSS OAK TRL
-----------------------------------------------------
City | LAKE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31636-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-362-8564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5314 MOSS OAK TRL
-----------------------------------------------------
City | LAKE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31636-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-362-8564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA8681
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------