Healthcare Provider Details

I. General information

NPI: 1174596415
Provider Name (Legal Business Name): JODIE LYNN BOLT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-1100
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1440
  • Fax: 253-968-0443
Mailing address:
  • Phone: 253-968-1440
  • Fax: 253-968-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number0101045084
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number0101045084
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberMD00035673
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD00035673
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: