Provider Demographics
NPI:1871810432
Name:JACKSON, SAGE MATTHEW (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:SAGE
Middle Name:MATTHEW
Last Name:JACKSON
Suffix:
Gender:M
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 1:1260 SMOKEHOUSE TRL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9301
Mailing Address - Country:US
Mailing Address - Phone:404-514-6654
Mailing Address - Fax:
Practice Address - Street 1:1260 SMOKEHOUSE TRL
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9301
Practice Address - Country:US
Practice Address - Phone:404-514-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist