Healthcare Provider Details

I. General information

NPI: 1811262637
Provider Name (Legal Business Name): JENNIFER JO-ANN BOBOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 WARREN ST
LOWELL MA
01852-2208
US

IV. Provider business mailing address

49 BEDARD AVE
DERRY NH
03038-4214
US

V. Phone/Fax

Practice location:
  • Phone: 978-452-1736
  • Fax:
Mailing address:
  • Phone: 603-505-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: