Provider Demographics
NPI:1831646801
Name:BOSWELL, JORDAN RENEA
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RENEA
Last Name:BOSWELL
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 1:105 WESTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901
Mailing Address - Country:US
Mailing Address - Phone:325-340-4020
Mailing Address - Fax:325-617-7809
Practice Address - Street 1:105 WESTLAND ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3051
Practice Address - Country:US
Practice Address - Phone:325-340-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388742355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38874OtherSPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY LICENSE