Provider Demographics
NPI:1992958680
Name:JACKSON, REGINA DEANNA SR (MSP CCC-SLP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:DEANNA
Last Name:JACKSON
Suffix:SR
Gender:F
Credentials:MSP CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 MARTHA ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5032
Mailing Address - Country:US
Mailing Address - Phone:803-206-7690
Mailing Address - Fax:
Practice Address - Street 1:910 MARTHA ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5032
Practice Address - Country:US
Practice Address - Phone:803-206-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4374235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist