MEDICARE: JACKSON FAMILY THERAPY SERVICES

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

General Provider Information

NPI Number	:	1871150672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON FAMILY THERAPY SERVICES

Provider Business Mailing Address
First Line	:	1630 ACADEMY DR APT 905
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-1711
Country	:	US
Telephone Number	:	334-477-3114
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 ACADEMY DR APT 905
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-1711
Country	:	US
Telephone Number	:	334-477-3114
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST/OWNER
Name	:	CANDACE JACKSON
Credential	:	MCD, CCC-SLP
Telephone Number	:	334-477-3114

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	05/28/2019

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Directions to “JACKSON FAMILY THERAPY SERVICES ” Practice Location

Language	Start Address	Practice Location

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