Provider Demographics
NPI:1003409269
Name:DUBOSE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 CROCKETT ST APT 1676
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3292
Mailing Address - Country:US
Mailing Address - Phone:936-635-5699
Mailing Address - Fax:
Practice Address - Street 1:300 ROE ST
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3106
Practice Address - Country:US
Practice Address - Phone:817-444-3235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist