Provider Demographics
NPI:1225613201
Name:BOLDEN, JATAYSIA S
Entity Type:Individual
Prefix:MRS
First Name:JATAYSIA
Middle Name:S
Last Name:BOLDEN
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 1:93 BALFOUR DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1138
Mailing Address - Country:US
Mailing Address - Phone:141-388-7787
Mailing Address - Fax:
Practice Address - Street 1:93 BALFOUR DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1138
Practice Address - Country:US
Practice Address - Phone:141-388-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician