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General NPI Number Information
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NPI Number | 1588470603
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Entity Type | Individual
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Provider Name | JODENE VENESSA JACKSON CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 2070 CENTURY PARK E
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City | LOS ANGELES
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State | CA
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Zip | 90067-1907
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Country | US
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Telephone | 424-522-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 839 ASHTON PARK CT
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-7090
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Country | US
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Telephone | 404-989-6842
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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 | 29257
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License Number State | CA
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