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General NPI Number Information
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NPI Number | 1275119521
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Entity Type | Individual
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Provider Name | JACQUELINE BOLIN
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Gender | Female
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Dates
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Enumeration Date | 03/18/2021
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Last Update Date | 01/10/2022
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Provider Practice Location Address
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Address Line | 1157 S CRISMON RD
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City | MESA
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State | AZ
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Zip | 85208-2661
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Country | US
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Telephone | 480-776-3790
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Fax |
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Provider Business Mailing Address
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Address Line | 14247 S 47TH PL
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City | PHOENIX
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State | AZ
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Zip | 85044-6206
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Country | US
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Telephone | 480-521-3825
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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