Basic Information
| Provider Information | |||||||||
| NPI: | 1568807717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | SLPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17103 E CYPRUS POINT CT | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN HILLS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852685704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025253516 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5314 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2013 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | SLPA8234 | AZ | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.