Doctor Name: | MRS. TARA MICHELE JACKSON |
NPI Number: | 1114973559 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | MA, CCC-SLP |
License Number: | 5772 |
Business Practice Address: | 3403 Linden Berry Ln Charlotte, NC - 282691300 |
Business Phone Number: | 7042581724 |
Business Fax Number: | 7045983024 |
Mailing Address: | 3403 Linden Berry Lane, CHARLOTTE |
State: | NC |
Postal Code: | 282691300 |
Phone Number: | 7048982437 |
Fax Number: | |
NPI Enumeration Date: | 05/26/2006 |
NPI Last Update Date: | 07/02/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 235Z00000X |
License Number: | 5772 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NC |
Taxonomy Type: | Speech, Language and Hearing Service Providers |
Taxonomy Classification: | Speech-Language Pathologist |
Taxonomy Specialization: | |
Taxonomy Definition: | A speech pathologist is a person qualified by a master |