Provider Demographics
NPI:1497986392
Name:YEARY, JANICE B (MSE, CCC, SLP)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:B
Last Name:YEARY
Suffix:
Gender:F
Credentials:MSE, 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:PO BOX 100722
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0722
Mailing Address - Country:US
Mailing Address - Phone:817-247-0654
Mailing Address - Fax:817-847-0205
Practice Address - Street 1:3901 W VICKERY BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5672
Practice Address - Country:US
Practice Address - Phone:817-247-0654
Practice Address - Fax:817-847-0205
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80T421OtherBLUE CROSS BLUE SHIELD
TX203986901Medicaid