MEDICARE: CHRISTINE B JACKSON S.L.P.

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	16509	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811050172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE B JACKSON S.L.P.

Provider Business Mailing Address
First Line	:	6125 E BELKNAP ST
Second Line	:
City	:	HALTOM CITY
State	:	TX
Zip	:	76117-4296
Country	:	US
Telephone Number	:	817-547-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	6125 E BELKNAP ST
Second Line	:
City	:	HALTOM CITY
State	:	TX
Zip	:	76117-4296
Country	:	US
Telephone Number	:	817-547-5700
Fax Number	:

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	04/21/2022

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