Healthcare Provider Details

I. General information

NPI: 1891818803
Provider Name (Legal Business Name): FLETA JOY YOUNGBLOOD LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 W LAMAR ST
JASPER TX
75951-4014
US

IV. Provider business mailing address

RT. 5 BOX 15
KIRBYVILLE TX
75956
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-6829
  • Fax: 409-384-4770
Mailing address:
  • Phone: 409-423-3807
  • Fax: 409-423-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number19736
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: