Provider Demographics
NPI:1184923757
Name:JACKSON, CAROLINE J (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:J
Other - Last Name:MCKOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:804 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-7100
Mailing Address - Country:US
Mailing Address - Phone:985-839-9816
Mailing Address - Fax:985-839-4794
Practice Address - Street 1:610 T W BARKER DR
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-1549
Practice Address - Country:US
Practice Address - Phone:985-839-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0890235Z00000X
LA3224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230121Medicaid
MS255271Medicare PIN
MS1912997685Medicare UPIN