Healthcare Provider Details

I. General information

NPI: 1689115008
Provider Name (Legal Business Name): JENNIFER BOLES SCOTT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 06/07/2025
Certification Date: 06/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

688 BARCLAY LN
BROOMALL PA
19008-1011
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2169
  • Fax:
Mailing address:
  • Phone: 610-550-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.152099
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberMT226907
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: