Provider Demographics
NPI:1457050213
Name:YOUNGBLOOD, JACIE
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:YOUNGBLOOD
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:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:WINK
Mailing Address - State:TX
Mailing Address - Zip Code:79789-0637
Mailing Address - Country:US
Mailing Address - Phone:432-527-3880
Mailing Address - Fax:
Practice Address - Street 1:200 NORTH ROSEY DODD
Practice Address - Street 2:
Practice Address - City:WINK
Practice Address - State:TX
Practice Address - Zip Code:79789
Practice Address - Country:US
Practice Address - Phone:432-527-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist