1518085331 NPI number — KATHERINE MARIE JACKSON MA, CCC-SLP

Table of content: KATHERINE MARIE JACKSON MA, CCC-SLP (NPI 1518085331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518085331 NPI number — KATHERINE MARIE JACKSON MA, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
KATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518085331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1734 W CRESTLINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80120-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-794-2201
Provider Business Mailing Address Fax Number:
303-504-9945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6595 S DAYTON ST
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
GREENWOOD VILLAGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80111-6128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-504-9945
Provider Business Practice Location Address Fax Number:
303-504-9946
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  01108932 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35653264 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 649046 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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