Provider Demographics
NPI:1366544322
Name:JACKSON, DAVID MAX (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MAX
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 PEREGRINE CT
Mailing Address - Street 2:
Mailing Address - City:W LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 PEREGRINE CT
Practice Address - Street 2:
Practice Address - City:W LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-5073
Practice Address - Country:US
Practice Address - Phone:765-426-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002292A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist