Provider Demographics
NPI:1093024630
Name:BOLING, JACK WESLEY JR (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WESLEY
Last Name:BOLING
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 HALPINE RD
Mailing Address - Street 2:APT #1337
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1661
Mailing Address - Country:US
Mailing Address - Phone:904-334-8158
Mailing Address - Fax:
Practice Address - Street 1:3200 TOWER OAKS BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4216
Practice Address - Country:US
Practice Address - Phone:301-881-4610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23441225100000X
FL25803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist