Provider Demographics
NPI:1639897127
Name:JACKSON, JULIE CAROLINE (SLP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:CAROLINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12033 WILD BILL CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:TX
Mailing Address - Zip Code:76071-8944
Mailing Address - Country:US
Mailing Address - Phone:817-688-3270
Mailing Address - Fax:
Practice Address - Street 1:350 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2249
Practice Address - Country:US
Practice Address - Phone:817-744-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109406235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist