MEDICARE: NICOLE JACKSON PETERS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	120406	TX

General Provider Information

NPI Number	:	1588388854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JACKSON PETERS CCC-SLP

Provider Business Mailing Address
First Line	:	4020 MONTERREY OAKS
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-5228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 MONTERREY OAKS
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-5228
Country	:	US
Telephone Number	:	512-393-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/22/2023

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