Provider Demographics
NPI:1306834221
Name:BOLLER, JEAN (MS,CCC-A)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:BOLLER
Suffix:
Gender:F
Credentials:MS,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 E HILDEBRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2693
Mailing Address - Country:US
Mailing Address - Phone:210-824-0063
Mailing Address - Fax:210-824-8514
Practice Address - Street 1:603 E HILDEBRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2693
Practice Address - Country:US
Practice Address - Phone:210-824-0063
Practice Address - Fax:210-824-8514
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50862237600000X, 237700000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX90166OtherHEARING AID DISPENSING
TX50862OtherSTATE LICENSE NUMBER
TX151653604Medicaid
TXS06153Medicare UPIN