Provider Demographics
NPI:1942780655
Name:BALBOA, JESSLEE DANELLE
Entity Type:Individual
Prefix:
First Name:JESSLEE
Middle Name:DANELLE
Last Name:BALBOA
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 1:7500 TALLEY RD LOT 39
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-4621
Mailing Address - Country:US
Mailing Address - Phone:361-775-5405
Mailing Address - Fax:
Practice Address - Street 1:1440 RIVER RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-1958
Practice Address - Country:US
Practice Address - Phone:830-816-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX365327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist