Demetria Jackson, CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

SLP007195 Issued in GA

Practice address

157 Coral Dr
Brunswick, GA 31523-8951

Phone

(912) 689-4382

Fax

(888) 875-2884

NPI assigned

Jun 2, 2010

Last updated

Feb 4, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Innovative Therapy Matters LLC

  • Speech-Language Pathologist
  • Brunswick, GA
  • NPI 1235584020
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1275436800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643932800000",
    "number": "1790005791",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2246",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315212246",
            "telephone_number": "912-689-4382",
            "fax_number": "888-875-2884"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "157 CORAL DR",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315238951",
            "telephone_number": "912-689-4382",
            "fax_number": "888-875-2884"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "DEMETRIA",
        "credential": "CCC-SLP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2010-06-02",
        "last_updated": "2022-02-04",
        "certification_date": "2022-02-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "GA",
            "license": "SLP007195",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "658178836A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• J.H. Harvey Co., LLC (Harveys Supermarket Pharmacy #2312)
• J.H. Harvey Co., LLC (Harveys Supermarket Pharmacy #2397)
• Seema Banu Jabbar
• Pauline Laggui Jacinto, M.D.
• Avanelle V Jack, MD
• Ebony Jackson
• Jenna L. Jackson
• Jennifer Jackson, RN
• Kierra Jackson
• Loretta Patrice Jackson, LCSW

• Speech-Language Pathologist in Brunswick, GA
• Providers in Brunswick, GA by specialty
• Speech-Language Pathologist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.