Provider Demographics
NPI:1174767685
Name:JACKSON, JOI
Entity type:Individual
Prefix:MS
First Name:JOI
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 1:3249 LIBERTY COMMONS DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2322
Mailing Address - Country:US
Mailing Address - Phone:770-826-1334
Mailing Address - Fax:
Practice Address - Street 1:3249 LIBERTY COMMONS DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2322
Practice Address - Country:US
Practice Address - Phone:770-826-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist