Provider Demographics
NPI:1942539838
Name:BOLES, JACQUELINE M (LMFT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:BOLES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 MEDICAL PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7904
Mailing Address - Country:US
Mailing Address - Phone:512-765-6788
Mailing Address - Fax:
Practice Address - Street 1:1603 MEDICAL PKWY STE 320
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7904
Practice Address - Country:US
Practice Address - Phone:512-765-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
TX202770106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942539838OtherLMFT