Healthcare Provider Details

I. General information

NPI: 1548088578
Provider Name (Legal Business Name): JACLYN BALES-ALLEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 N LAMAR BLVD
AUSTIN TX
78756-4080
US

IV. Provider business mailing address

191 ANN POWELL RD
SMITHVILLE TX
78957-5704
US

V. Phone/Fax

Practice location:
  • Phone: 512-407-7000
  • Fax:
Mailing address:
  • Phone: 512-575-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1080561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: