Provider Demographics
NPI:1144529959
Name:BOLTON, JONELL HAMILTON
Entity type:Individual
Prefix:
First Name:JONELL
Middle Name:HAMILTON
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 O'DONOVAN BLVD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:WALKER
Mailing Address - State:LA
Mailing Address - Zip Code:70785-6351
Mailing Address - Country:US
Mailing Address - Phone:225-271-6550
Mailing Address - Fax:225-271-6551
Practice Address - Street 1:5000 O'DONOVAN BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-6351
Practice Address - Country:US
Practice Address - Phone:225-271-6550
Practice Address - Fax:225-271-6551
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207163208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2149890Medicaid
LA2149890Medicaid