Provider Demographics
NPI:1174170591
Name:JACKSON, CHRISTY DANIELLE (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:D
Other - Last Name:VIJJESWARAPU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:29 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2629
Practice Address - Country:US
Practice Address - Phone:864-331-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116020235Z00000X
SC7582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist