Provider Demographics
NPI:1508277468
Name:BOULAVSKY, JESSICA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BOULAVSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20326 TX-249
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070
Mailing Address - Country:US
Mailing Address - Phone:281-501-5599
Mailing Address - Fax:
Practice Address - Street 1:20326 TX-249
Practice Address - Street 2:SUITE 400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:281-501-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA274611207N00000X
TXR4193207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology