MEDICARE: SHIALOH JORDYN STUBLESKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1083415129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIALOH JORDYN STUBLESKI

Provider Business Mailing Address
First Line	:	2929 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-5711
Country	:	US
Telephone Number	:	817-532-3302
Fax Number	:	817-532-3302

Provider Business Practice Location Address
First Line	:	2929 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-5711
Country	:	US
Telephone Number	:	817-532-3302
Fax Number	:	817-532-3302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	03/24/2025

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Directions to “ SHIALOH JORDYN STUBLESKI ” Practice Location

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