Provider Demographics
NPI:1487336921
Name:JACKSON, ALEXANDRA MAYNARD (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MAYNARD
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:NICOLE
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:11622 W RYAN PL
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-2188
Mailing Address - Country:US
Mailing Address - Phone:913-378-4768
Mailing Address - Fax:
Practice Address - Street 1:929 N SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist