Provider Demographics
NPI:1134185234
Name:BOLEY, JASON MORRIS (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MORRIS
Last Name:BOLEY
Suffix:
Gender:M
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:979-703-6485
Practice Address - Street 1:1700 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2661
Practice Address - Country:US
Practice Address - Phone:979-691-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM06682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8H9043OtherBC/BS PROVIDER NUMBER
TX174299103Medicaid
TX182843601Medicaid
TXP00663817OtherMEDICARE RAILROAD
TX8X7829OtherBCBS
TX174299106Medicaid
TXI31377Medicare UPIN
TX00N59XMedicare PIN
TX8J1607Medicare PIN