Provider Demographics
NPI:1215487921
Name:BOLZENIUS, JACLYN (M A)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BOLZENIUS
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 TOWN AND 4 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6225
Mailing Address - Country:US
Mailing Address - Phone:636-697-5880
Mailing Address - Fax:
Practice Address - Street 1:10560 OLD OLIVE STREET RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5916
Practice Address - Country:US
Practice Address - Phone:314-567-4707
Practice Address - Fax:314-567-4505
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016020606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist