Provider Demographics
NPI:1073841367
Name:BOLGER, JACKALYN (RN)
Entity Type:Individual
Prefix:
First Name:JACKALYN
Middle Name:
Last Name:BOLGER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22067 SE HOWLETT RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97022-9764
Mailing Address - Country:US
Mailing Address - Phone:503-637-3631
Mailing Address - Fax:
Practice Address - Street 1:22067 SE HOWLETT RD
Practice Address - Street 2:
Practice Address - City:EAGLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97022-9764
Practice Address - Country:US
Practice Address - Phone:503-637-3631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2002242564RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse