Provider Demographics
NPI:1639407919
Name:CHAN, JODIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 FLEWELLEN OAKS LN STE 604
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-1858
Mailing Address - Country:US
Mailing Address - Phone:281-969-3692
Mailing Address - Fax:281-969-7301
Practice Address - Street 1:5757 FLEWELLEN OAKS LN STE 604
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-1858
Practice Address - Country:US
Practice Address - Phone:281-969-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13815645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639407919Medicaid