Provider Demographics
NPI:1164034484
Name:PAGE, JACQUELYN MICHELLE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:PAGE
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 1:2251 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-2117
Mailing Address - Country:US
Mailing Address - Phone:956-456-5425
Mailing Address - Fax:
Practice Address - Street 1:4851 S I 35 E STE 100
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76210-2348
Practice Address - Country:US
Practice Address - Phone:940-435-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist