Provider Demographics
NPI:1033095211
Name:JACKSON, ASHA NICOLE (SLP)
Entity type:Individual
Prefix:
First Name:ASHA
Middle Name:NICOLE
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 1:116 RICH ANGEL DR
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-6449
Mailing Address - Country:US
Mailing Address - Phone:337-296-7413
Mailing Address - Fax:
Practice Address - Street 1:118 W 10TH ST
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-6202
Practice Address - Country:US
Practice Address - Phone:985-536-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist