Provider Demographics
NPI:1316172778
Name:JACKSON, STACI TATE (SLP)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:TATE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 SOUTHWIN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4634
Mailing Address - Country:US
Mailing Address - Phone:336-287-2175
Mailing Address - Fax:
Practice Address - Street 1:4917 SOUTHWIN DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4634
Practice Address - Country:US
Practice Address - Phone:336-287-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6933235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist