Provider Demographics
NPI:1023379526
Name:BOLEN, JASON (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BOLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 DUCKWOOD DR
Mailing Address - Street 2:102
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1090
Mailing Address - Country:US
Mailing Address - Phone:651-964-1010
Mailing Address - Fax:
Practice Address - Street 1:1380 DUCKWOOD DR
Practice Address - Street 2:102
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1090
Practice Address - Country:US
Practice Address - Phone:651-964-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350005070OtherMEDICARE
MN1023379526Medicaid