=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861935173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB EDWARD BOLL DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 JEFFERSON RIVER RD
-----------------------------------------------------
City | THREE FORKS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59752-9765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-260-0831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 JEFFERSON RIVER RD
-----------------------------------------------------
City | THREE FORKS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59752-9765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-260-0831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH60706123
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHI-CHI-LIC-4595
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------