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General NPI Number Information
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NPI Number | 1205048824
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Entity Type | Individual
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Provider Name | J. MICHELE JACKSON CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 2235 CALIFORNIA AVE SW
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City | CAMDEN
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State | AR
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Zip | 71701-5605
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Country | US
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Telephone | 870-836-2654
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Fax |
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Provider Business Mailing Address
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Address Line | 288 CHOCTAW RDG
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City | EL DORADO
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State | AR
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Zip | 71730-2250
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Country | US
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Telephone | 870-918-2894
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 706
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License Number State | AR
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