MEDICARE: JACQUELINE BOLIN

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1275119521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE BOLIN

Provider Business Mailing Address
First Line	:	14247 S 47TH PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6206
Country	:	US
Telephone Number	:	480-521-3825
Fax Number	:

Provider Business Practice Location Address
First Line	:	1157 S CRISMON RD
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-2661
Country	:	US
Telephone Number	:	480-776-3790
Fax Number	:

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

Provider Enumeration Date	:	03/18/2021
Last Update Date	:	01/10/2022

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Directions to “ JACQUELINE BOLIN ” Practice Location

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