Healthcare Provider Details

I. General information

NPI: 1306373642
Provider Name (Legal Business Name): JACKELINE BOBADILLA MSPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 PINELAND DR
DALLAS TX
75231-5300
US

IV. Provider business mailing address

5750 PINELAND DR
DALLAS TX
75231-5300
US

V. Phone/Fax

Practice location:
  • Phone: 214-221-0855
  • Fax:
Mailing address:
  • Phone: 214-221-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA18520
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18520
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: