Provider Demographics
NPI:1306501481
Name:POE, JACIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:POE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 WOODLAND PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-1908
Mailing Address - Country:US
Mailing Address - Phone:432-900-2095
Mailing Address - Fax:432-400-2676
Practice Address - Street 1:4425 W WADLEY AVE UNIT 230-A
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-5330
Practice Address - Country:US
Practice Address - Phone:432-900-2095
Practice Address - Fax:432-400-2676
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114130235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist