Provider Demographics
NPI:1225700305
Name:BOLANOS, JENNIFER BERENICE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BERENICE
Last Name:BOLANOS
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 1:8043 MITCHELL DR APT 30
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-8162
Mailing Address - Country:US
Mailing Address - Phone:707-933-6913
Mailing Address - Fax:
Practice Address - Street 1:8043 MITCHELL DR APT 30
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-8162
Practice Address - Country:US
Practice Address - Phone:707-933-6913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker