Provider Demographics
NPI:1861210775
Name:JACKSON, INDIA
Entity type:Individual
Prefix:
First Name:INDIA
Middle Name:
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 1:6315 ROBINS TRCE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4979
Mailing Address - Country:US
Mailing Address - Phone:404-414-0866
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3390
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-502-7800
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP013295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist