Provider Demographics
NPI:1407664402
Name:JACKSON, AMELIA (MS, SLP-CCC)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N CANVASBACK DR
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4641
Mailing Address - Country:US
Mailing Address - Phone:801-726-6487
Mailing Address - Fax:
Practice Address - Street 1:18406 W WHITE QUEST DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84013-9701
Practice Address - Country:US
Practice Address - Phone:801-335-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12333349-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty