Provider Demographics
NPI:1598294027
Name:BROOKS, JACI SUE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:SUE
Last Name:BROOKS
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 1:5149 GOODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6204
Mailing Address - Country:US
Mailing Address - Phone:432-770-1784
Mailing Address - Fax:
Practice Address - Street 1:3611 DICKASON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4912
Practice Address - Country:US
Practice Address - Phone:214-559-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111462235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111462OtherTEXAS STATE LICENSE