Provider Demographics
NPI:1447346929
Name:JACKMAN, KIMBERLY A (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4296 SEA ROCK COURT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4832
Mailing Address - Country:US
Mailing Address - Phone:407-222-0046
Mailing Address - Fax:270-818-1558
Practice Address - Street 1:4296 SEA ROCK COURT
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-4832
Practice Address - Country:US
Practice Address - Phone:407-222-0046
Practice Address - Fax:270-818-1558
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4259235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA 4259OtherSTATE LICENSE NUMBER