Provider Demographics
NPI:1255069266
Name:FLEET, JACEY MICHELLE
Entity type:Individual
Prefix:
First Name:JACEY
Middle Name:MICHELLE
Last Name:FLEET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MARLIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-0623
Mailing Address - Country:US
Mailing Address - Phone:903-238-4900
Mailing Address - Fax:
Practice Address - Street 1:5303 OLD HIGHWAY 135 N
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-6808
Practice Address - Country:US
Practice Address - Phone:903-984-4416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist