Provider Demographics
NPI:1063980167
Name:JACKSON, NATALIE KRISTENE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:KRISTENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 JILL LN
Mailing Address - Street 2:
Mailing Address - City:BONO
Mailing Address - State:AR
Mailing Address - Zip Code:72416-9691
Mailing Address - Country:US
Mailing Address - Phone:870-219-2231
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:AR
Practice Address - Zip Code:72432-1930
Practice Address - Country:US
Practice Address - Phone:870-578-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200308235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist