Healthcare Provider Details

I. General information

NPI: 1982371860
Provider Name (Legal Business Name): JACLYN RUTH BOLEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 SCARBROUGH LN
SHADY SPRING WV
25918-8590
US

IV. Provider business mailing address

141 SCARBROUGH LN
SHADY SPRING WV
25918-8590
US

V. Phone/Fax

Practice location:
  • Phone: 304-578-1983
  • Fax:
Mailing address:
  • Phone: 304-578-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberDP00946319
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: