Provider Demographics
NPI:1497877831
Name:BALDAZO, JESSICA RENEE (SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:BALDAZO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 N JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-4962
Mailing Address - Country:US
Mailing Address - Phone:956-283-6353
Mailing Address - Fax:
Practice Address - Street 1:4004 N JACKSON RD
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-4962
Practice Address - Country:US
Practice Address - Phone:956-283-6353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102444235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102444OtherTX STATE BOARD ST