Provider Demographics
NPI:1417197344
Name:JACKSON, IRENE SHETZLINE (MA CCCSLP)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:SHETZLINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-3424
Mailing Address - Country:US
Mailing Address - Phone:703-772-2449
Mailing Address - Fax:
Practice Address - Street 1:1006 S COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-3424
Practice Address - Country:US
Practice Address - Phone:703-772-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004915235Z00000X
MD4622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist