Provider Demographics
NPI:1275370496
Name:JACKSON, LIVIA
Entity type:Individual
Prefix:
First Name:LIVIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 S COLEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MANHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:17545-8654
Mailing Address - Country:US
Mailing Address - Phone:717-917-6158
Mailing Address - Fax:
Practice Address - Street 1:1045 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7201
Practice Address - Country:US
Practice Address - Phone:301-750-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist