MEDICARE: MRS. JENNIFER RUTH BOLLER BCABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	103K00000X	Behavior Analyst	2014028750	MO

General Provider Information

NPI Number	:	1548509664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER RUTH BOLLER BCABA

Provider Business Mailing Address
First Line	:	1002 E 23RD AVENUE
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116
Country	:	US
Telephone Number	:	816-835-0262
Fax Number	:	816-984-8281

Provider Business Practice Location Address
First Line	:	5863 NW 72ND ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-1483
Country	:	US
Telephone Number	:	816-984-8280
Fax Number	:	816-984-8281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2013
Last Update Date	:	01/20/2023

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