Provider Demographics
NPI:1245336874
Name:JACKSON, JANETTE RHODES (SLP)
Entity type:Individual
Prefix:MS
First Name:JANETTE
Middle Name:RHODES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-7020
Mailing Address - Country:US
Mailing Address - Phone:803-534-8609
Mailing Address - Fax:803-534-8609
Practice Address - Street 1:1264 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-7020
Practice Address - Country:US
Practice Address - Phone:803-534-8609
Practice Address - Fax:803-534-8609
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0025Medicaid