Basic Information
| Provider Information | |||||||||
| NPI: | 1639305014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON JADE & ASSOCIATES, A SPEECH PATHOLOGY CORPORATION | ||||||||
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| OtherOrganizationName: | JACKSON JADE SPEECH, OCCUPATIONAL & PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 E OCEAN BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888087838 | ||||||||
| FaxNumber: | 8666203943 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 E OCEAN BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888087838 | ||||||||
| FaxNumber: | 8666203943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2009 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | FIRBY | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8888087838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.