Provider Demographics
NPI:1730708975
Name:JACKSON, NANCY ANGELIA (MS-CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:ANGELIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 VILLA CREEK DR STE 140
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7385
Mailing Address - Country:US
Mailing Address - Phone:469-250-3524
Mailing Address - Fax:
Practice Address - Street 1:2655 VILLA CREEK DR STE 140
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7385
Practice Address - Country:US
Practice Address - Phone:469-250-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist