Provider Demographics
NPI:1205071370
Name:WRIGHT BOSTOCK, JOLENE M (MS, CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:M
Last Name:WRIGHT BOSTOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 N WELLSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0857
Mailing Address - Country:US
Mailing Address - Phone:208-939-6418
Mailing Address - Fax:
Practice Address - Street 1:560 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5029
Practice Address - Country:US
Practice Address - Phone:208-737-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist