Provider Demographics
NPI:1528190030
Name:MOLINA, JACLYN (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:
Last Name:MOLINA
Suffix:
Gender:F
Credentials:MA CCC-SLP
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 291
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-0291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 MAHOGANY CHEST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-1524
Practice Address - Country:US
Practice Address - Phone:210-690-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX528509OtherBLUE CROSS BLUE SHIELD