Provider Demographics
NPI:1609165505
Name:JACK, KEMBERLEE J (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KEMBERLEE
Middle Name:J
Last Name:JACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16562 BECKLAND LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-6541
Mailing Address - Country:US
Mailing Address - Phone:214-519-4984
Mailing Address - Fax:
Practice Address - Street 1:16562 BECKLAND LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-6541
Practice Address - Country:US
Practice Address - Phone:214-519-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX358252355S0801X
GASLP010119235Z00000X
LA8201235Z00000X
TX115500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant