Provider Demographics
NPI:1730420407
Name:JACKSON, NATALIE MARIE
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BARBER PL
Mailing Address - Street 2:CONTRACTING BOX 92
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1863
Mailing Address - Country:US
Mailing Address - Phone:814-878-4111
Mailing Address - Fax:814-874-5505
Practice Address - Street 1:100 BARBER PL
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1863
Practice Address - Country:US
Practice Address - Phone:814-878-4111
Practice Address - Fax:814-874-5505
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist