Provider Demographics
NPI:1609353184
Name:JACKSON, WENDI WALLACE (SLP)
Entity type:Individual
Prefix:
First Name:WENDI
Middle Name:WALLACE
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 1:3429 CHERRY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5641
Mailing Address - Country:US
Mailing Address - Phone:850-890-8546
Mailing Address - Fax:
Practice Address - Street 1:301 W 26TH ST
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4713
Practice Address - Country:US
Practice Address - Phone:850-769-5371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13768235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist