Provider Demographics
NPI:1326609918
Name:BOLLER, JESSICA ANN (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANN
Last Name:BOLLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 INDIAN SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3617
Mailing Address - Country:US
Mailing Address - Phone:714-400-1095
Mailing Address - Fax:
Practice Address - Street 1:15 CALLE ALUMBRADO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6709
Practice Address - Country:US
Practice Address - Phone:949-682-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-38095103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst