Provider Demographics
NPI:1386067585
Name:JACKSON, TIA (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 GREENSBURY DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-9055
Mailing Address - Country:US
Mailing Address - Phone:614-946-7836
Mailing Address - Fax:
Practice Address - Street 1:1545 HUY RD
Practice Address - Street 2:COLUMBUS CITY SCHOOLS SPEECH DEPARTMENT
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-3531
Practice Address - Country:US
Practice Address - Phone:614-365-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist