Provider Demographics
NPI:1992787543
Name:MCLEAN, JODI (AUD)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 VANCE JACKSON RD
Mailing Address - Street 2:SUITE 156
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5336
Mailing Address - Country:US
Mailing Address - Phone:210-341-0451
Mailing Address - Fax:210-341-5834
Practice Address - Street 1:4402 VANCE JACKSON RD
Practice Address - Street 2:SUITE 156
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5336
Practice Address - Country:US
Practice Address - Phone:210-341-0451
Practice Address - Fax:210-341-5834
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50528237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1506073-04Medicaid
TX1506073-04Medicaid