Provider Demographics
NPI:1871805085
Name:PRATHER, JACKSON MONROE (MED CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:MONROE
Last Name:PRATHER
Suffix:
Gender:M
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 OLD PAGE RD APT 334
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8095
Mailing Address - Country:US
Mailing Address - Phone:919-215-3262
Mailing Address - Fax:
Practice Address - Street 1:100 MEREDITH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5237
Practice Address - Country:US
Practice Address - Phone:919-484-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist