Healthcare Provider Details

I. General information

NPI: 1982233250
Provider Name (Legal Business Name): JENESSA BOLENBAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 HILLCREST PARK DR STE 102
MEDFORD OR
97504-7684
US

IV. Provider business mailing address

3250 HILLCREST PARK DR STE 102
MEDFORD OR
97504-7684
US

V. Phone/Fax

Practice location:
  • Phone: 541-773-7409
  • Fax:
Mailing address:
  • Phone: 541-773-7409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number10196768
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: