Provider Demographics
NPI:1881911725
Name:JACKSON, CHARLEEN A (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CHARLEEN
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815
Mailing Address - Country:US
Mailing Address - Phone:607-244-1707
Mailing Address - Fax:
Practice Address - Street 1:9 DIVISION ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-2030
Practice Address - Country:US
Practice Address - Phone:607-244-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist