=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306501481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACIE POE M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4425 W WADLEY AVE UNIT 230-A
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-5330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-900-2095
-----------------------------------------------------
Fax | 432-400-2676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 WOODLAND PARK AVE
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79705-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-900-2095
-----------------------------------------------------
Fax | 432-400-2676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 114130
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------