Provider Demographics
NPI:1912165044
Name:JEZAK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JEZAK
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 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-335-2597
Practice Address - Street 1:3220 GUS THOMASSON RD STE 356
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4051
Practice Address - Country:US
Practice Address - Phone:972-613-4182
Practice Address - Fax:972-686-1837
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50654237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist