Healthcare Provider Details

I. General information

NPI: 1225700305
Provider Name (Legal Business Name): JENNIFER BERENICE BOLANOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 ARNOLD DR
SONOMA CA
95476-3290
US

IV. Provider business mailing address

17000 ARNOLD DR
SONOMA CA
95476-3290
US

V. Phone/Fax

Practice location:
  • Phone: 707-996-7965
  • Fax: 707-996-7965
Mailing address:
  • Phone: 707-996-7965
  • Fax: 707-996-7965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: