MEDICARE: JACKALYN BOLGER R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	2002242564RN	OR

General Provider Information

NPI Number	:	1073841367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKALYN BOLGER R.N.

Provider Business Mailing Address
First Line	:	22067 SE HOWLETT RD
Second Line	:
City	:	EAGLE CREEK
State	:	OR
Zip	:	97022-9764
Country	:	US
Telephone Number	:	503-637-3631
Fax Number	:

Provider Business Practice Location Address
First Line	:	22067 SE HOWLETT RD
Second Line	:
City	:	EAGLE CREEK
State	:	OR
Zip	:	97022-9764
Country	:	US
Telephone Number	:	503-637-3631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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