Healthcare Provider Details

I. General information

NPI: 1568055325
Provider Name (Legal Business Name): JESSICA NOELLE ROBERTSON MS., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6502 SLIDE RD STE 204
LUBBOCK TX
79424-1311
US

IV. Provider business mailing address

7013 24TH ST
LUBBOCK TX
79407-4343
US

V. Phone/Fax

Practice location:
  • Phone: 806-686-0429
  • Fax:
Mailing address:
  • Phone: 325-201-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number41481
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number118424
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: