Provider Demographics
NPI:1376835199
Name:RODDY, JEANINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:RODDY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11330 LEGACY DR STE 306
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-1217
Mailing Address - Country:US
Mailing Address - Phone:469-630-2328
Mailing Address - Fax:
Practice Address - Street 1:11330 LEGACY DR STE 306
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-1217
Practice Address - Country:US
Practice Address - Phone:469-630-2328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12137620235Z00000X
TX235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist