Provider Demographics
NPI:1174184931
Name:BOLT, JACOB ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:BOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:479-441-5011
Mailing Address - Fax:479-441-4932
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5011
Practice Address - Fax:479-441-4932
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-13356207P00000X, 207Q00000X
MO2019022911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine