Provider Demographics
NPI:1336624212
Name:JACKSON, DONNICE VERONICA
Entity type:Individual
Prefix:
First Name:DONNICE
Middle Name:VERONICA
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 1:611 PALMER RD APT 2R
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-5155
Mailing Address - Country:US
Mailing Address - Phone:404-734-5981
Mailing Address - Fax:
Practice Address - Street 1:65 COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4916
Practice Address - Country:US
Practice Address - Phone:718-935-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029779235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist