MEDICARE: JESSICA BOZZELL

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	235Z00000X	Speech-Language Pathologist	5977	NM
2	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1861874570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BOZZELL

Provider Business Mailing Address
First Line	:	1002 HILLRISE CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4764
Country	:	US
Telephone Number	:	505-459-5631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 HILLRISE CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4764
Country	:	US
Telephone Number	:	505-459-5631
Fax Number	:

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

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	07/22/2016

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Directions to “ JESSICA BOZZELL ” Practice Location

Language	Start Address	Practice Location

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