Basic Information
| Provider Information | |||||||||
| NPI: | 1982215885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | HELEN | ||||||||
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| Credential: | MAT, MCD, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2295 HENRY CLOWER BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300785707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709959600 | ||||||||
| FaxNumber: | 6783834556 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 OGLETHORPE AVE STE A2 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709959600 | ||||||||
| FaxNumber: | 6783834556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | PCET002870 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.