Healthcare Provider Details

I. General information

NPI: 1467940486
Provider Name (Legal Business Name): JEB BOLERJACK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-703-6400
  • Fax: 360-353-3611
Mailing address:
  • Phone: 360-636-3892
  • Fax: 360-414-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005027
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60344179
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: