Provider Demographics
NPI:1679222046
Name:CARLSON, JAXINE G
Entity Type:Individual
Prefix:
First Name:JAXINE
Middle Name:G
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY BLVD APT 525
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-8011
Mailing Address - Country:US
Mailing Address - Phone:701-353-9928
Mailing Address - Fax:
Practice Address - Street 1:4402 WILLIAMS DR STE 115
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1388
Practice Address - Country:US
Practice Address - Phone:512-256-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist