Provider Demographics
NPI:1093262313
Name:BOULAND, JESSIE (RN)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:BOULAND
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 1:750 BRIDGES
Mailing Address - Street 2:SUITE A
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396
Mailing Address - Country:US
Mailing Address - Phone:870-755-2737
Mailing Address - Fax:870-755-2740
Practice Address - Street 1:750 BRIDGES AVE E
Practice Address - Street 2:SUITE A
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-2327
Practice Address - Country:US
Practice Address - Phone:870-755-2737
Practice Address - Fax:870-755-2740
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR101869163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse