Provider Demographics
NPI:1104970458
Name:LIST, JAMIE SUZANNE (M ED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:SUZANNE
Last Name:LIST
Suffix:
Gender:F
Credentials:M ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9025 GANO DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2178
Mailing Address - Country:US
Mailing Address - Phone:501-765-0584
Mailing Address - Fax:
Practice Address - Street 1:1600 NAVO RD
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-3706
Practice Address - Country:US
Practice Address - Phone:972-347-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1484235Z00000X
TX108792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145337721Medicaid