Provider Demographics
NPI:1982941761
Name:HICKEY, JESSICA MATOCHA (SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MATOCHA
Last Name:HICKEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MICHELLE
Other - Last Name:MATOCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:201 WATERMERE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-8137
Mailing Address - Country:US
Mailing Address - Phone:817-337-7600
Mailing Address - Fax:817-431-8232
Practice Address - Street 1:201 WATERMERE DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8137
Practice Address - Country:US
Practice Address - Phone:817-337-7600
Practice Address - Fax:817-431-8232
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106843235Z00000X
CO0002374235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist