Provider Demographics
NPI:1588470603
Name:JACKSON, JODENE VENESSA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JODENE
Middle Name:VENESSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 ASHTON PARK CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7090
Mailing Address - Country:US
Mailing Address - Phone:404-989-6842
Mailing Address - Fax:
Practice Address - Street 1:2070 CENTURY PARK E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-1907
Practice Address - Country:US
Practice Address - Phone:424-522-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29257235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist