Provider Demographics
NPI:1245119791
Name:BOLTON, KIMBERLY J
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
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 1:712 EDGEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5337
Mailing Address - Country:US
Mailing Address - Phone:904-535-5365
Mailing Address - Fax:
Practice Address - Street 1:712 EDGEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-5337
Practice Address - Country:US
Practice Address - Phone:904-535-5365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-28
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator