Provider Demographics
NPI:1487889671
Name:JUMP START PEDIATRIC THERAPY CENTER, LLC
Entity type:Organization
Organization Name:JUMP START PEDIATRIC THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,COO, SPEECH-LANGUAGE PATHOLOG
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:SACHAR
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC -SLIP
Authorized Official - Phone:817-514-6333
Mailing Address - Street 1:7500 N. BEACH ST.
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137
Mailing Address - Country:US
Mailing Address - Phone:817-514-6333
Mailing Address - Fax:817-514-6334
Practice Address - Street 1:7500 N. BEACH ST.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:817-514-6333
Practice Address - Fax:817-514-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty