Provider Demographics
NPI:1558767772
Name:IRACHETA, JULISSA GAYLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JULISSA
Middle Name:GAYLE
Last Name:IRACHETA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:JULISSA
Other - Middle Name:GAYLE
Other - Last Name:SARGEANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8101 BOAT CLUB RD STE 160
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3631
Mailing Address - Country:US
Mailing Address - Phone:469-587-9397
Mailing Address - Fax:
Practice Address - Street 1:1140 W PIONEER PKWY STE A
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6383
Practice Address - Country:US
Practice Address - Phone:469-587-9397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-16
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 13419235Z00000X
TX107723235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist