Basic Information
| Provider Information | |||||||||
| NPI: | 1295321206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENOVESE | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | LARAE | ||||||||
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| Credential: | MED/MS/CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 SPRING VALLEY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752542512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144661340 | ||||||||
| FaxNumber: | 2144661378 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 SHILOH RD STE C120 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039392800 | ||||||||
| FaxNumber: | 9035093744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 18312 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.