Provider Demographics
NPI:1285811984
Name:MCKINNEY JACKSON, LISA DAWN (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:MCKINNEY JACKSON
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DAWN
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:105 THIRD AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840
Mailing Address - Country:US
Mailing Address - Phone:304-574-2268
Mailing Address - Fax:
Practice Address - Street 1:105 ADAIR ST
Practice Address - Street 2:RALEIGH COUNTY BOARD OF EDUCATION
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-256-4500
Practice Address - Fax:304-256-4739
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP0084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402057000Medicaid