Provider Demographics
NPI:1063256972
Name:RISNER-JACOX, KATHRYN SIMONE (M S)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SIMONE
Last Name:RISNER-JACOX
Suffix:
Gender:F
Credentials:M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14651 DALLAS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8856
Mailing Address - Country:US
Mailing Address - Phone:866-919-3240
Mailing Address - Fax:877-300-7394
Practice Address - Street 1:14651 DALLAS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8856
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:877-300-7394
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist