Healthcare Provider Details

I. General information

NPI: 1417103169
Provider Name (Legal Business Name): JENNIFER DIANE BOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 12/07/2025
Certification Date: 12/07/2025
Deactivation Date: 11/09/2025
Reactivation Date: 12/04/2025

III. Provider practice location address

1467 N WHITEASH AVE
CLOVIS CA
93619-8116
US

IV. Provider business mailing address

2511 JENSEN AVE
SANGER CA
93657-2251
US

V. Phone/Fax

Practice location:
  • Phone: 559-930-7147
  • Fax:
Mailing address:
  • Phone: 559-875-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: