Healthcare Provider Details

I. General information

NPI: 1558465831
Provider Name (Legal Business Name): JEANNETTE BOLTE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E SCENIC DR
PASS CHRISTIAN MS
39571-4417
US

IV. Provider business mailing address

PO BOX 195
PASS CHRISTIAN MS
39571-0195
US

V. Phone/Fax

Practice location:
  • Phone: 282-225-2032
  • Fax: 601-336-2662
Mailing address:
  • Phone: 228-222-5203
  • Fax: 601-336-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number40011
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: