Provider Demographics
NPI:1073241709
Name:BOETTCHER, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BOETTCHER
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:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:EAST BERNARD
Mailing Address - State:TX
Mailing Address - Zip Code:77435-1099
Mailing Address - Country:US
Mailing Address - Phone:832-477-5519
Mailing Address - Fax:
Practice Address - Street 1:5228 FM 2919 RD
Practice Address - Street 2:
Practice Address - City:EAST BERNARD
Practice Address - State:TX
Practice Address - Zip Code:77435-7469
Practice Address - Country:US
Practice Address - Phone:832-477-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist