Provider Demographics
NPI:1568717155
Name:BULLOCK, JACEY LAYNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:LAYNE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 PRAIRIE RUN
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-1170
Mailing Address - Country:US
Mailing Address - Phone:214-803-1699
Mailing Address - Fax:
Practice Address - Street 1:1015 CHAMPIONS DR # 102
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-3206
Practice Address - Country:US
Practice Address - Phone:214-803-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36944235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid
TX456606Medicare PIN